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0:00:07 The United States is one of just two countries that allow pharmaceutical firms to freely
0:00:11 advertise their products directly to consumers.
0:00:12 The other is New Zealand.
0:00:19 So if you ever watch TV in the US, you have likely seen many ads for prescription drugs.
0:00:22 But advertising doesn’t guarantee success.
0:00:26 The research and development of these drugs is very expensive, and most of them never
0:00:28 earn back their investment.
0:00:34 The pharmaceutical industry, therefore, relies on the occasional blockbuster drug.
0:00:38 A blockbuster defined as doing more than a billion dollars a year in sales.
0:00:44 If I asked you to name a blockbuster drug from the past, you might say Lipitor, a statin
0:00:51 originally from Park Davis, or Humera, an anti-inflammatory now sold by ABV, and can
0:00:54 you name a current blockbuster?
0:01:01 The first drug that comes to mind might be this one.
0:01:05 If you watch even a tiny bit of TV, you have probably seen an ad for Osempic.
0:01:11 Their jingle is sung to the tune of the 1974 pop hit Magic by a band called Pilot, which
0:01:16 had exactly one US hit.
0:01:22 Osempic, which is sold by the Danish multinational Novo Nordisk, is not a one-hit wonder.
0:01:29 It is one of a group of drugs known as GLP-1s, and many Americans would agree that they are
0:01:31 magic.
0:01:39 GLP stands for glucagon-like peptide, which is a hormone produced in the human gut, and
0:01:42 these drugs mimic the activity of that hormone.
0:01:48 Osempic was developed to treat type 2 diabetes, which used to be called adult onset diabetes
0:01:52 to distinguish it from the more serious type 1 diabetes, which most often occurs in young
0:01:54 people.
0:01:58 But those lines have blurred, as many more people around the world, including a lot of
0:02:02 young people, are now getting type 2 diabetes.
0:02:06 Diabetes is a condition whereby the pancreas can’t produce enough insulin to modulate
0:02:09 your level of glucose, or blood sugar.
0:02:15 Over the long term, high blood sugar can lead to all kinds of problems, so any drug that
0:02:20 could help the body produce more insulin would be a blockbuster.
0:02:22 Enter osempic.
0:02:24 But wait, there’s more.
0:02:28 Osempic and other GLP-1s don’t just lower blood sugar.
0:02:36 They also help patients lose weight, primarily by slowing digestion and decreasing appetite.
0:02:42 This secondary discovery, weight loss, was a big deal, especially in the US, where more
0:02:47 than 40% of the adult population is obese.
0:02:52 Even though researchers don’t know much about the long-term effects of GLPs, whether they
0:02:58 remain effective over time, whether they have serious side effects, the take-up has been
0:03:00 enthusiastic.
0:03:05 Osempic and Wagovie, another GLP drug made by Novo Nordisk, and which is authorized to
0:03:12 treat obesity, will do a combined $65 billion in global sales this year.
0:03:17 Novo Nordisk is now worth more than the GDP of Denmark.
0:03:21 And Novo Nordisk isn’t the only company making blockbuster GLPs.
0:03:27 Another big one is Moundjaro, which was brought to market in 2022 by the American pharmaceutical
0:03:28 firm Eli Lilly.
0:03:35 Moundjaro works by mimicking two digestive proteins, GLP-1 and GIP.
0:03:40 Most of these new drugs are, for now, injectables, although that will change and some are already
0:03:42 in pill form.
0:03:45 And these drugs aren’t cheap, at least not yet.
0:03:50 In the US, they can cost more than $1,000 a month, and as we will hear today, insurance
0:03:52 coverage varies widely.
0:04:01 Still, more than 15 million Americans are already using these drugs, so is the magic real or
0:04:03 maybe too good to be true?
0:04:08 I think your skepticism is well-placed, and that’s why we do trials to find out.
0:04:14 Today, on Freakin’omics Radio, we continue our December of one-on-one conversations with
0:04:20 Ezekiel Emanuel, who is pretty excited about these GLP-1 drugs.
0:04:25 This is why people do science, because you discover something and then lots of unexpected
0:04:26 effects happen.
0:04:33 Emanuel is an oncologist, a medical ethicist, a professor, and a healthcare policymaker.
0:04:36 He helped design the Affordable Care Act, better known as Obamacare.
0:04:40 He also worked on healthcare policy in the Trump White House.
0:04:46 In today’s conversation, we talk about why many insurers don’t want to cover the GLP
0:04:47 drugs.
0:04:53 We’ve created a system that perfectly disincentivizes long-term investments.
0:05:00 We talk about progress in cancer treatment, mysteries in the gut microbiome, and flaws
0:05:02 in the US healthcare system.
0:05:03 Don’t get me started.
0:05:06 We got to have a whole ‘nother conversation about that issue.
0:05:11 And we talk about what healthcare policy looks like in a second Trump term.
0:05:14 Even Republicans want everyone to have health insurance.
0:05:16 We’re not repealing the Affordable Care Act.
0:05:32 All that and quite a bit more with Ezekiel Emanuel starting now.
0:05:38 This is Freakonomics Radio, the podcast that explores the hidden side of everything with
0:05:49 your host Stephen Dubner.
0:05:54 If the last name Emanuel sounds familiar, it may be because Zeke Emanuel has a couple
0:05:59 of brothers who, over the years, have also appeared on this show.
0:06:04 There’s Ram Emanuel, former Obama Chief of Staff in Chicago Mayor, who was serving as
0:06:09 US Ambassador to Japan when we spoke with him in 2023.
0:06:18 Ram is known to be smart, tough, and reliably combative.
0:06:23 That episode was called the Suddenly Diplomatic Ram Emanuel.
0:06:28 When there is Arielle Emanuel, who runs the entertainment and sports firms Endeavor and
0:06:34 TKO, his business is high profile, but for himself he tends to keep a lower profile.
0:06:40 This may date back to his childhood as the youngest brother in a very competitive household.
0:06:43 Ari thought of himself as the dumb one.
0:06:47 You know, the grades would come up with poor cards on the fridge.
0:06:49 I was competing with Zeke.
0:06:50 There was no chance.
0:06:54 He was the debater, shut up.
0:06:58 That episode was called Ari Emanuel is Never Indifferent.
0:07:03 Zeke Emanuel is the oldest brother, the one who took the trouble to write a family memoir
0:07:05 called The Brothers Emanuel.
0:07:09 He leans more toward collaborative than combative.
0:07:14 He has also been on Freakonomics Radio before, most recently in an episode called Who Gets
0:07:18 the Ventilator, which we published early in the COVID pandemic, when ventilators were
0:07:22 thought to be an effective frontline treatment.
0:07:23 Here’s a clip from that episode.
0:07:29 If it sounds like it was recorded in a closet because of COVID, it probably was.
0:07:36 First comfort serve is the absolute worst principle you can think of in this situation.
0:07:41 That was a really interesting conversation about how medical resources should be allocated
0:07:42 in times of scarcity.
0:07:48 In the case of ventilators, scarcity was caused by lack of physical supply.
0:07:53 In the case of this new generation of GLP-1 drugs, there has been some supply shortage,
0:07:59 but the scarcity for many would-be patients is caused by their high prices.
0:08:04 High prices and inadequate coverage in the healthcare industry are always a topic of
0:08:10 great concern as we’ve seen lately in the fallout from the murder of Brian Thompson,
0:08:15 the CEO of the insurance firm United Healthcare.
0:08:22 I knew that Zeke Emanuel could give us a 360-degree view of the GLP revolution, so I began by
0:08:28 asking him when he first became aware of these drugs, maybe in medical school?
0:08:29 No.
0:08:32 I did not come across him in medical school, even though I went to Harvard Medical School
0:08:37 and a lot of the early work was done at the Massachusetts General Hospital.
0:08:39 Which is a Harvard-affiliated hospital?
0:08:40 Exactly.
0:08:42 Just down the block.
0:08:48 One of the groups at the Mass General Hospital was taking pancreases out of fish and then
0:08:53 testing how they affect glucose in other models.
0:08:58 And they ran across what’s called the proglucogon, a very long protein that makes glucagon, but
0:09:07 it also makes the GLP-1 agent that affects the glucose levels in the blood.
0:09:12 It was the 1990s when they showed that GLP-1s normalized blood sugars.
0:09:14 That was really important.
0:09:23 And then in 1996, researchers in Britain identified that the GLP-1s caused a loss of appetite.
0:09:29 Jens Holst in Copenhagen worked with Novo Nordisk, which is one of the big pharma companies
0:09:37 that has produced insulin and was very active in the diabetes field, to make the first GLP-1
0:09:40 drug for diabetes.
0:09:43 That was done by a woman named Latti Knudsen.
0:09:47 In 2010, they created that first drug.
0:09:53 And then in 2014, the indication was expanded to obesity because they saw that, you know,
0:09:56 diabetics also lost weight.
0:10:04 The GLP-1s from Novo Nordisk, Wagovia or Osempic, they are really impactful both in terms of
0:10:05 decreasing weight.
0:10:11 With Wagovia, you get about 15%, 16% weight reduction, but also very good at bringing
0:10:14 down blood sugars for diabetics.
0:10:20 And then when you add the other component, the GIP, Monjero, that’s the lily drug, you
0:10:24 get even more weight drop, 21%.
0:10:29 And we know that Wagovia, the GLP-1, has a lot of other effects.
0:10:30 It protects the heart.
0:10:37 A 20% drop in severe cardiac death from heart attacks, number of heart attacks, strokes,
0:10:40 goes down 20%, which is pretty amazing.
0:10:43 It protects from severe kidney disease.
0:10:45 It protects from cirrhosis.
0:10:49 And we’ve got hints that there are lots of other effects, psychiatric effects.
0:10:51 Addiction, you’ve mentioned.
0:10:55 Depression, I was going to say addiction, you beat me to it.
0:11:00 Or even because obesity and diabetes are associated with increased risk of cancer.
0:11:06 Honestly, as you described that, Zeke, it sounds like this class of drugs is too good
0:11:07 to be true.
0:11:13 You’ve called them a miraculous set of drugs before we get further into the upsides.
0:11:16 What about downsides and/or side effects?
0:11:19 As I like to say, even a blood test has side effects.
0:11:24 The major side effects tend to be with the gastrointestinal tract, as you might expect.
0:11:30 As he tends to be at the top of the list, diarrhea, constipation, some fullness because
0:11:34 it slows emptying of the stomach.
0:11:40 About a quarter of people have these side effects and it’s variable in how much people
0:11:41 experience it.
0:11:44 I’ve talked to people on these drugs and they have it minimal.
0:11:49 I’ve talked to other people and they have quit the drugs because they really found it
0:11:50 intolerable.
0:11:56 As you’re describing the multiple uses, treatment, but also prophylactic for all these different
0:12:01 conditions, it sounds almost as if you would recommend that these drugs go in the water
0:12:02 supply.
0:12:08 No, I am very enthusiastic, but there are some more serious side effects.
0:12:10 One of the most serious is pancreatitis.
0:12:17 That is inflammation of the pancreas can cause severe abdominal pain and other problems.
0:12:20 It’s pretty rare, but it’s not unheard of.
0:12:24 There’s also some cosmetic side effects when you lose the fat out of your face.
0:12:29 You can get this hollow cheek look and a lot of wrinkles.
0:12:35 I do think these could be more widely used, especially for people with obesity, but unlike
0:12:39 some other drugs that I do think probably need to be in the water supply, these need
0:12:41 to be used a little more selectively.
0:12:47 I’m curious how you and others foresaw how useful they’d be, not only for weight loss
0:12:50 and diabetes, but potentially all these other treatments.
0:12:55 I’m curious what your view of them was like, what the skepticism was like, and who’s skeptical
0:12:56 now maybe.
0:13:01 First of all, I was not fully focused on how beneficial they could be.
0:13:07 I have to give credit to Novo Nordisk and Lilly for doing trials that didn’t just look
0:13:12 at diabetes or didn’t just look at obesity, but looked at more outcomes.
0:13:17 For the clinicians who identified, “Wow, we’re seeing these other positive effects.”
0:13:21 People eating less, the addictions to alcohol and drugs going down.
0:13:25 I’m sorry to interrupt, Zeke, but on something like that, when you’re talking about clinical
0:13:29 treatment, doctor treatments, and they’re saying they’re observing that their patients
0:13:35 are having fewer problems in these other realms, whether drinking, eating, I mean, how empirical
0:13:36 is that?
0:13:40 Because I could imagine that someone who feels like they are improving on one dimension of
0:13:46 their life maybe changes their behavior in response to positive feeling, a kind of not
0:13:51 quite placebo, but something that was spurred on by one positive effect that has these other
0:13:56 positive knock-on effects as opposed to actually treating addiction and so on.
0:14:01 I think your skepticism is well-placed, and that’s why we do trials, to find out we’re
0:14:03 in a huge number of trials.
0:14:07 On the other hand, there are some things like looking at livers.
0:14:10 How does the liver change with these drugs?
0:14:12 That’s not going to be a placebo effect.
0:14:14 That is actually going to be a drug effect.
0:14:18 And something like addiction, especially things like alcohol and drugs, where we know it’s
0:14:25 so hard to stop, when you do see lots of people on these drugs stopping and reporting that
0:14:28 they don’t have the craving, you have to take that seriously.
0:14:33 That doesn’t mean it can’t be a placebo effect, but it affects the gut, it affects the pancreas
0:14:38 to increase insulin, and it obviously has to affect the brain if it’s going to affect
0:14:41 these addictions and psychiatric situations.
0:14:48 And that’s what is probably the most remarkable and unexpected finding here, that this big
0:14:53 protein somehow is getting across the blood-brain barrier or somehow is being released there,
0:14:58 and being able to affect people’s mental situation.
0:15:01 On all the reading I did on this, and I have to admit a lot of the science is really hard
0:15:06 for me, at least, and maybe many lay people to understand, but it sounds as though there
0:15:12 are a couple different mechanisms, or maybe different drug classes work in different mechanisms,
0:15:18 but it sounds as though there is a body effect, a kind of cellular body effect, and a brain
0:15:19 effect.
0:15:23 Is one drug causing both of those, or are they different drugs that do that?
0:15:31 Well, we don’t know for sure, but probably the same drug or some way that it’s causing
0:15:33 a pathway effect.
0:15:36 But that’s not understood yet, you’re saying, fully.
0:15:38 Probably the brain effect.
0:15:42 Sometimes great things happen that have multiple applications.
0:15:47 Since the end of the genome project in roughly 2000, we’ve had five big breakthroughs in
0:15:49 healthcare.
0:15:51 We’ve had CRISPR, where you can edit genes.
0:15:57 We’ve had gene therapy, where I use this term, the researchers are a little more cautious.
0:15:58 Really cure blindness.
0:16:03 We’ve had CAR T therapy, where again the researchers are a little more cautious, but you cure people
0:16:06 of cancer who are on their death bed.
0:16:12 We’ve had the mRNAs, and now we’re multiple uses for mRNA items, not just vaccines, but
0:16:14 in many, many other ways.
0:16:16 And you’ve had these GLP ones.
0:16:21 Each of these have way more ramifications than we ever thought possible.
0:16:26 Let’s take a step back on that front and talk about where research funding and research
0:16:28 incentives are coming from these days.
0:16:34 The five treatments that you’ve just named are evidence of how things are working in
0:16:36 medical science.
0:16:38 As we all know, a lot of these routes are very meandering.
0:16:39 They take a long time.
0:16:44 There are all kinds of failures and dead ends when you’re doing this kind of research.
0:16:49 How do you feel about the current state of moonshot medical advances?
0:16:54 And I’m especially curious to know how you would assess the private public collaboration
0:16:55 there.
0:17:00 Well, let me say we need public and private collaboration, because each part does different
0:17:01 things.
0:17:08 Mainly, the government invests a lot in basic research and tries to create understanding
0:17:10 of how these pathways work.
0:17:15 And let’s be honest, deciding what you’re going to fund is based upon judgment of the
0:17:19 community, and the community, like any community, has prejudices.
0:17:24 It’s pursuing one avenue rather than all the avenues.
0:17:30 And we know that sometimes has been an inhibition to good and high-risk research.
0:17:34 The government often doesn’t like to have failures on research.
0:17:40 One of the criticisms I have is the government has more or less ceded most of the clinical
0:17:42 research to drug companies.
0:17:48 Now, drug companies obviously have a big investment, but they have a particular kind of investment
0:17:55 comparing different drugs in the same class or comparing one drug, like GLP-1s, with another
0:18:01 drug like the SGLT-2s that might be used for diabetes.
0:18:05 That’s not so much in their interest unless they think they’re going to easily win that
0:18:06 race.
0:18:09 But the government should be doing a lot of that comparative assessment.
0:18:14 And yet the NIH has gotten — it’s not out of clinical research, but it’s reduced its
0:18:17 footprint in clinical research a lot.
0:18:20 And that, I think, is a bad thing.
0:18:22 You know, we need drug companies.
0:18:27 They can fund these big trials, but we have to recognize they have their own interests
0:18:33 at heart, which don’t necessarily correspond to the national public health interest.
0:18:37 We’ve got to have them because they know how to scale, they know how to market the drugs,
0:18:43 they know how to chemically adjust the drugs to increase how long they last in the body.
0:18:48 We can’t underestimate convenience is really important because for a chronic illness you
0:18:51 have to stay on the drug often forever.
0:18:57 I’ve heard you say that one big problem with medicine today is that 86% of all spending
0:18:59 goes to chronic conditions.
0:19:05 In the case of the GLP-1 drugs, widespread adoption would, I assume, over time bring
0:19:07 down those costs dramatically.
0:19:11 I know we’re talking about high costs in the short term, but I assume in the long term
0:19:13 the costs would fall a lot.
0:19:16 First of all, tell me if that’s indeed the case.
0:19:21 And second, if you look really big picture, how you think about all that money potentially
0:19:27 being reallocated to research, treatment, prevention, cure, et cetera.
0:19:32 Well, Stephen, let’s be clear with the listener.
0:19:36 We have to separate out something that is cost-saving.
0:19:41 We pay for it now, but it’ll save money over time from something that is cost-effective,
0:19:47 which means the total amount we pay is still worth it, but it doesn’t save money.
0:19:52 So far on the GLP-1, the cost analysis does not show us saving money.
0:19:54 But I think you’re right.
0:20:01 We’ve got 42% of the adult population obese, 20% of U.S. children obese, 10% of the U.S.
0:20:04 adult population has type 2 diabetes.
0:20:10 If we can treat those illnesses, reduce things like hospital admissions, hypertension, cardiac
0:20:14 disease, kidney disease, the liver disease that goes with them, maybe we will be able
0:20:16 to save money.
0:20:17 Here’s the problem.
0:20:22 Even if we could show that over a 10-year time horizon, they were cost-saving, that society
0:20:29 would get back more money than we paid for the drug by saving other medical costs, hospitalizations,
0:20:34 other drugs, replacement of hips and things like that, we’ve created a healthcare system
0:20:38 where it’s not in the system’s interest to make those long-term cost-savings.
0:20:39 What do you mean by that?
0:20:42 Are you talking about the incentives of the insurance companies?
0:20:47 Say you’re sitting at United or Humana or a Blue Cross and Blue Shield.
0:20:53 You have a person called them 30 years old who you’re insuring, you’re going to spend
0:20:58 money today for them, and the payoffs going to dribble out in five, six, seven years when
0:21:03 they’ve gone for a long time with their diabetes under control or they’ve gone for a long time
0:21:05 ceasing to be obese.
0:21:11 The problem is, by the time those positive benefits come and the cost-savings come, they’re
0:21:13 no longer being insured by you.
0:21:17 We call this in the medical health policy world churn.
0:21:24 The churn is so much in the insurance market that that investment horizon for companies
0:21:27 is not five, six, seven years.
0:21:30 It tends to be one year and maximum two years.
0:21:34 Is that primarily because health insurance is tied to employment in this country?
0:21:36 It’s a large reason for it.
0:21:40 People change jobs, lose jobs, move.
0:21:45 They get married and they switch from their insurance to their spouse’s insurance.
0:21:51 We’ve created a system that perfectly disincentivizes long-term investments, and that’s bad when
0:21:55 chronic illness is the main source of costs.
0:22:01 So we’re going to have to change how we structure the insurance marketplace, and no one’s talking
0:22:04 about that at the moment.
0:22:07 Okay, let’s us talk about it.
0:22:10 My conversation with Zeke Emanuel continues after the break.
0:22:15 I’m Stephen Dubner, and I’d like to thank you for listening to Freakonomics Radio, not
0:22:17 just today, but always.
0:22:27 We’ll be right back.
0:22:32 We’ve been talking with the oncologist and healthcare policymaker, Zeke Emanuel, about
0:22:38 the large and sudden uptake of GLP-1 drugs, which were designed to treat diabetes, but
0:22:41 have also been found to have other effects.
0:22:46 They help people lose weight, drink less, even have more sex drive.
0:22:53 This GLP revolution will no doubt produce a variety of downstream effects, not just physiological
0:22:56 and psychological, but political and economic effects.
0:23:00 There will be behavior change and social change.
0:23:03 What will all these changes look like?
0:23:04 I have no idea.
0:23:06 And no one else does, either.
0:23:09 If they say they do, you should start walking in the other direction.
0:23:16 Predicting the future is hard, uncertainty is real, and as we often preach on this show,
0:23:19 unintended consequences can be powerful.
0:23:24 So let’s plan on following those long-term effects as they unspool, but for now, let’s
0:23:28 get back to the near-term effects of these drugs.
0:23:32 One big problem with GLP-1s is that they are expensive.
0:23:35 So a big question is, who pays for them?
0:23:41 What is the responsibility of health insurers, whether we’re talking private firms or government
0:23:42 plans?
0:23:46 How much should any government directly subsidize these drugs?
0:23:50 And how much are these drugs worth to society?
0:23:54 These are some of the questions that Zeke Emanuel and several colleagues tried to answer
0:23:59 in a recent article published in The Lancet, a prominent English medical journal.
0:24:06 They offer, as their subtitle says, “a review and ethical analysis of discordant approaches.”
0:24:10 I asked Emanuel why he took on this project.
0:24:14 The prior article we published in the New England Journal was about how to ethically
0:24:21 allocate the resources of the GLP-1 drugs, and we establish a framework that puts younger
0:24:26 obese patients at the top, along with diabetic patients who aren’t responding to other treatments.
0:24:30 And so we had the natural question, what are other countries doing?
0:24:34 We always look to other countries who think they’ve got to have a better system.
0:24:38 And one of the things you learn is, well, the Germans, they got the same allocation
0:24:40 as we do in Medicare.
0:24:43 They don’t cover any of these weight loss drugs.
0:24:47 Then you stumble upon other countries, like Australia and Denmark, and they say, oh, these
0:24:52 drugs aren’t cost-effective, but in fact, they use long outdated cost-effectiveness before
0:24:55 all the benefits for heart disease and liver disease.
0:24:59 Long outdated, you mean just like 2022, two years ago.
0:25:00 Exactly.
0:25:05 But in a rapidly changing field, you have to be nimble, and you have to use the absolute
0:25:06 latest data.
0:25:11 And then we see a whole series of countries where they’re worried about the total cost,
0:25:15 and they’re just saying we’re not covering it, which is the wrong policy.
0:25:19 Drug prices might be high, but there are some people who need the drugs more than other
0:25:21 people where the benefits are going to be greater.
0:25:24 You should cover it for those people.
0:25:28 And let’s remember, these aren’t the only expensive drugs in the marketplace.
0:25:29 I’m an oncologist.
0:25:34 Every oncology drug is super expensive, none are cheap unless they’re generic.
0:25:40 We cover those, and their benefits are probably way less than Osempic or Wagovia or Mungero.
0:25:44 Because with cancer drugs, you’re sometimes talking about a life extension of just weeks
0:25:48 or months versus potentially many years with these GLP-1s.
0:26:00 The life extension for a severely obese patient could be five to ten years, and that’s real.
0:26:03 Here are some key statistics from the Lancet paper.
0:26:09 Emanuel and his colleagues analyzed GLP-1 policy in 13 high-income countries, including
0:26:15 the U.S. and the U.K. All 13 of them cover the cost of GLP-1s for at least some people
0:26:21 with type 2 diabetes, but nine of the 13 countries deny reimbursement for weight management.
0:26:27 The U.S. is perhaps the most hodgepodgey of these 13 countries, given its mix of federal,
0:26:29 state, and private health care coverage.
0:26:34 I asked Emanuel to start from the beginning and describe just how much variance there is
0:26:36 from place to place.
0:26:43 Well, almost every country covers it for diabetes, but we’ve got a lot of countries that don’t
0:26:45 cover it at all for weight loss.
0:26:53 Australia, Belgium, Denmark, Finland, Germany, Italy, Israel, okay?
0:26:54 Don’t cover it.
0:26:59 Canada also doesn’t have a national policy, so it’s a little more variable.
0:27:09 The 13 countries for France, Iceland, Japan, and then the U.K. under some conditions cover
0:27:13 ozempic, wagovi, manjaro, and the conditions vary.
0:27:19 So France, you have to have a high BMI or if a slightly lower BMI and severe comorbidities
0:27:21 from obesity.
0:27:25 The U.K., you also have to change your diet and exercise.
0:27:30 And then there’s Iceland which says, “Look, we’ll cover it, but you’re going to have to
0:27:33 have serious weight loss if you’re not actually losing weight.
0:27:34 We’re going to not cover it.”
0:27:38 So you can get started on it, but if you haven’t lost weight within a certain time, your coverage
0:27:40 will be pulled, essentially?
0:27:41 Exactly.
0:27:46 And, you know, if I had to pick one, I would say I like what France is doing and I like
0:27:52 what the U.K. does in terms of it’s not just about drugs, it’s about a whole lifestyle,
0:27:54 change, and give people help with doing that.
0:27:57 I think those are the right directions to go.
0:28:01 Since you and I and much of our audience are American and since Americans are particularly
0:28:07 solipsistic, let’s talk about the American circumstance with coverage, but also price.
0:28:12 So one thing I learned from your papers that the price is charged for GLPs in different
0:28:14 countries very massively.
0:28:21 I believe it’s around 280 some dollars in Japan to $1350 in the U.S.
0:28:25 Most of all, it shows you that there’s price flexibility, that these drug companies are
0:28:29 willing to change the price depending upon what governments or others require.
0:28:33 Was that your brother who negotiated the 283 in Japan, you think?
0:28:34 He is a good negotiator.
0:28:35 I’ll say that.
0:28:36 He’s also a cheapskate.
0:28:38 I’ll say that too.
0:28:41 So I think that’s actually a positive.
0:28:43 That makes me optimistic.
0:28:49 And if I were in charge, if I were the health czar in the United States, I would go to these
0:28:53 drug companies and I would say, “Listen, let’s get a subscription model.
0:28:56 We’re going to give you a flat fee so you make money and you’re going to give us an
0:29:01 unlimited amount of these drugs because actually to produce these drugs is not that expensive.
0:29:07 And we’re going to try to get everyone we can who qualifies on these drugs.”
0:29:10 That’s a deal I think everyone could be happy with.
0:29:15 The drug company will make a lot of money and the country will be able to treat more
0:29:18 people and will be better off.
0:29:23 It won’t also be just to first come, first serve if you’ve got a lot of money.
0:29:27 What is a budget that would be reasonable to spend on people with obesity and diabetes?
0:29:32 That’s our limit for spending and it’s probably going to be pretty good given, I think it’s
0:29:39 less, I looked, $173 billion we spend on obesity-related healthcare.
0:29:42 So we have tens of billions, you might say we could spend.
0:29:47 So we could make it enticing for a drug company but also good for public health.
0:29:51 Economists, as I’m sure you know, like to talk about what they call moral hazard, which
0:29:59 is if you make some behavior less costly by ensuring it or protecting against it somehow,
0:30:01 then people are freer to do it.
0:30:10 So I’m thinking, “Well, if I can now have my GLP-1 that is going to keep my weight down,
0:30:16 prevent diabetes and prevent all these other potential complications, heck, I can eat whatever
0:30:19 I want whenever I want because medicine has helped me out.”
0:30:24 But there’s also the idea that food is medicine, right, that nutrition is important well beyond
0:30:25 the weight component.
0:30:32 So having permission to eat garbage calories would be at best a partial victory.
0:30:34 So how do you think about that balance?
0:30:36 Here’s a positive.
0:30:43 We have focused more on obesity and we’ve also understood better that it is not simply
0:30:45 a lifestyle choice.
0:30:50 It has to do both with the body and therefore it’s very biologic and it has to do with
0:30:52 our social environment, the food.
0:30:58 You know, today we have 20% of our children are defined as obese and 16% is overweight
0:31:03 and within that obese category, 6% are severely obese.
0:31:05 That is a terrible place to be.
0:31:08 We’ve got type 2 diabetes in young kids, hypertension in young kids.
0:31:14 We have to reverse that and that isn’t going to be a Monjiro or Wadovi or Ozempic solution.
0:31:19 That has to be a solution of changing their diets and getting them more exercise.
0:31:22 There’s just no alternative to that.
0:31:28 We need to invest more in the public health of our children and encouraging their parents
0:31:35 to change their diet and maybe more than encouraging using things like taxes and other mechanisms,
0:31:38 school lunches, school breakfast to change that behavior.
0:31:44 I mean, this is a song I’ve been hearing for probably 20 or 30 years now.
0:31:45 Absolutely.
0:31:49 But, Steve, because so much attention has been focused on obesity now because of these
0:31:54 drugs and because we can realize, “Oh, you can change that by giving a drug that must
0:31:56 be a biological thing.
0:31:59 It’s not simply a weakness of will that you’re eating more.”
0:32:03 I’m hoping that changes our culture around obesity.
0:32:08 And look, when I started thinking, “Well, we’ve got a limited amount of these GLP drugs.
0:32:10 Who should get the GLP drugs?”
0:32:15 When I started doing that research, my thinking was, “It’s got to be the diabetic patients.
0:32:16 They’re going to benefit the most.”
0:32:19 And then I get into this and I begin thinking, “All right.
0:32:20 What are we trying to do?
0:32:22 We’re trying to save the most lives.”
0:32:25 And then I said, “Well, who loses the most years of life?”
0:32:28 It turns out it’s the people with obesity.
0:32:34 My own analysis changed my ethical judgment here when you look at these data.
0:32:38 The people who are really suffering are people with obesity.
0:32:41 They’re the people who are going to benefit the most from these drugs.
0:32:45 Most insurance companies don’t want to cover it because it’s a big expense.
0:32:46 Medicaid is all over the place.
0:32:47 Some states are covering it.
0:32:49 Most states are not.
0:32:52 The consequence is, you know, who’s getting GLP ones?
0:32:53 Rich people.
0:32:59 That is the totally unethical, unjust way of allocating these very important pathbreaking
0:33:00 drugs.
0:33:08 We have to change our system so that we actually do the ethical thing, and that so far is not
0:33:11 where we’re headed.
0:33:15 We recorded this conversation with Zeke Emanuel back in September before the presidential
0:33:16 election.
0:33:22 Since we spoke, the Biden administration proposed a new plan to have Medicare and Medicaid
0:33:26 cover GLP-1 drugs like Osempic and Mound jarrow.
0:33:31 As of now, Medicaid coverage varies from state to state, as we just heard.
0:33:36 And Medicare doesn’t reimburse for these drugs at all because of a law prohibiting the coverage
0:33:38 of weight loss products.
0:33:45 This proposed new coverage would cost an estimated $35 billion over a decade, or $3.5 billion
0:33:50 a year, which sounds like a lot until you put it up against what Emanuel told us the
0:33:58 U.S. spends each year on obesity-related healthcare, around $175 billion.
0:34:03 It’s too early to say what will happen to the Biden administration’s GLP-1 proposal
0:34:05 under the Trump administration.
0:34:10 Trump’s pick for director of health and human services, Robert F. Kennedy Jr., has criticized
0:34:16 GLP-1s, but Mehmet Oz, Trump’s pick to run the Centers for Medicare and Medicaid Services,
0:34:18 has expressed support.
0:34:24 I did ask Zika Manuel during our interview how big of a shift he would envision in U.S.
0:34:27 healthcare policy if Trump won the election.
0:34:34 If I were a betting man, having worked with Donald Trump, this isn’t going to be a priority
0:34:35 of his.
0:34:40 He may make another run at repealing the Affordable Care Act, but that’s a joke.
0:34:41 It’s not going to happen.
0:34:43 It’s a joke because it’s ensconced.
0:34:45 It’s just not going to happen.
0:34:49 John Republicans in Congress, I talked to him right after John McCain did his thumbs
0:34:53 down and killed the repeal, and he said, “Oh, I’m very close.
0:34:54 I’m going to do it again.
0:34:55 We’re going to get it this time.”
0:35:01 I said, “Mr. President, what you don’t realize is that behind John McCain, if he hadn’t
0:35:06 done that, there were 10 other senators who would have rejected it because it would have
0:35:09 upset things too much in their state.
0:35:14 Every single state that has tried to expand Medicaid where the voters had to say, the
0:35:19 voters said, “Expand Medicaid,” and we’re talking about deep, deep red states, places
0:35:23 like Oklahoma, places like South Dakota.
0:35:26 Even Republicans want everyone to have health insurance.
0:35:28 We’re not repealing the Affordable Care Act.
0:35:32 You’re well-known for your involvement in the Affordable Care Act.
0:35:35 You’re also well-known for having written several books.
0:35:40 One of them published, I believe it was 2014, was called Reinventing American Health Care,
0:35:46 how the Affordable Care Act will improve our terribly complex, blatantly unjust, outrageously
0:35:50 expensive, grossly inefficient, error-prone system.
0:35:52 That’s a lot of promise for one subtitle.
0:35:55 How well do you think that promise has been met?
0:35:59 So far, I think it’s been met reasonably well.
0:36:01 Here’s how I would put it.
0:36:04 It’s dramatically increased coverage.
0:36:08 Tens of millions of people have gotten health insurance and gotten the benefits of health
0:36:13 insurance, including less mortality, less stress, less anxiety.
0:36:20 Secondly, it’s actually led to a plateau in healthcare spending as a percentage of GDP.
0:36:26 We were at 17.5% of GDP spent on healthcare when we started with the Affordable Care Act,
0:36:27 and guess what?
0:36:29 We’re at the exact same place.
0:36:31 That’s trillions of dollars of savings.
0:36:36 To be fair, that’s a larger share of GDP than any other country in the world by a long shot.
0:36:37 Don’t get me started.
0:36:39 You’ve got to have a whole nother conversation about that issue.
0:36:44 I could go on and on about it, but yes, we spend — I think Switzerland’s the next highest
0:36:47 country in terms of spending about 8,000 per person.
0:36:51 We’re close to 13,000 or maybe even over 13,000 per person.
0:36:54 So yes, we’re burning lots of money that we shouldn’t be burning.
0:36:59 In any case, those are two big accomplishments of the Affordable Care Act.
0:37:03 It’s also, by getting more people insured, led to some cost savings.
0:37:10 On the quality side, I would say much more uneven, not consistently beneficial.
0:37:12 And for me, it’s been a disappointment.
0:37:16 We still have high levels of hypertension, high levels of diabetes, worsening mental
0:37:18 health crises.
0:37:23 On the issue of equity, lots of people are concerned about minorities and others not
0:37:24 getting as much.
0:37:29 The fact is, we have narrowed the uninsured rate between minorities and whites.
0:37:32 So we’ve done okay there, I would say.
0:37:36 We haven’t evened everything out, but I think we’ve done okay.
0:37:42 I’d say the one big place where it’s gone awry is the dissatisfaction with the health
0:37:49 care system is higher, a lot more barriers and hurdles, more prior authorization, both
0:37:55 for patients and doctors, harder to find doctors for your particular condition.
0:38:00 And also, even though we have the same GDP spending, the out-of-pocket spending’s gone
0:38:05 up, employers are shifting more costs to individuals through higher deductibles and
0:38:08 things like that, that leads to frustration and stress.
0:38:13 So I do think the Affordable Care Act has achieved a lot, but the underlying defects
0:38:20 of the system prevent us from achieving all the goals we need to achieve with health care.
0:38:23 And how can those goals be achieved?
0:38:25 This is a problem in our country.
0:38:27 We have to move with the times.
0:38:29 We have to be more innovative.
0:38:33 Next coming up, after the break, I’m Stephen Dovner, speaking with Ezekiel Emanuel on
0:38:34 Freakonomics Radio.
0:38:43 We will be right back.
0:38:47 Let’s talk about the future of medicine generally, but especially I’m curious to know what you
0:38:53 think AI and machine learning and so on will do to, you know, accelerate discovery, treatment,
0:38:54 et cetera, et cetera.
0:38:59 I want to frame this with an observation I heard from Mustafa Suleiman, who’s an AI
0:39:02 entrepreneur, I guess you’d call him now at Microsoft.
0:39:09 I heard him say that if AI proceeds as he sees it, that the cost of medical diagnosis
0:39:11 will eventually drop to zero.
0:39:14 Now let’s say he’s only 30% right.
0:39:19 There’s a 30% cost savings on diagnosis, but that’s massive.
0:39:25 I’m curious how you think in a world where that’s true, how that money gets reallocated?
0:39:31 Well, first of all, Stephen, I was just at a meeting that my brother put on and every
0:39:34 panel talked about AI and the promise of AI.
0:39:36 And I do think there’s a lot of promise there.
0:39:38 Don’t get me wrong.
0:39:44 But I also think that it’s going to take longer to make it into the healthcare system, because
0:39:49 first of all, you got to spread it out over 330 million people, which means not that it’s
0:39:55 hard to scale AI, but you have to make sure it doesn’t bias you against certain populations
0:39:58 or ignore problems in certain populations.
0:40:02 And to some extent, the training systems are not good at that.
0:40:06 I also think there’s some hesitation in using it.
0:40:09 I do think the biggest advantage is going to be in access.
0:40:14 People who can’t get to the doctor, that’s actually going to turn out to be a huge benefit.
0:40:15 I should say conflict adventures.
0:40:18 I’m involved in several companies looking at that.
0:40:21 There are other huge advantages.
0:40:25 One of them is diagnoses, identifying people who are likely to have complications.
0:40:29 So you can intervene now and prevent a hospitalization and save money.
0:40:34 So I am optimistic over a slightly longer time horizon.
0:40:39 If I were reallocating that 30%, here’s my top priorities.
0:40:45 Priority number one, invest in children and as early as possible.
0:40:48 Even before they’re out of the womb, you got to invest in them.
0:40:53 We know early interventions produce the biggest social benefit.
0:41:00 So right when they’re born, have nurse family partnerships so that families are supported.
0:41:01 We have to have daycare.
0:41:04 That’s cheaper so people can afford it.
0:41:07 Mandatory, pre-K, open to everyone.
0:41:10 I would also bring down the total healthcare costs for people.
0:41:15 One of the major things is we need to put a cap on out-of-pocket expenditures, deductibles
0:41:19 and copays so people don’t go bankrupt and aren’t stressed by the cost.
0:41:27 I think a maximum of $1,000 for a family is probably a place I would like to get to.
0:41:29 You also need to spend that money and other things.
0:41:30 It’s not just healthcare.
0:41:35 We need to spend it on infrastructure so that we can have housing and people can commute
0:41:38 without having to drive hours and hours.
0:41:44 So the COVID pandemic taught pretty much everyone how to use Zoom or some equivalent.
0:41:49 And this was plainly vital for medicine at the time, what we now call telemed or telehealth.
0:41:56 I’m curious what you see as the lasting effects of that telehealth surge during COVID, pros
0:42:00 and cons of, let’s say, continuing to lean on virtual medicine.
0:42:03 I think in general, it’s positive.
0:42:08 We had a big blip up almost half of the physician engagement’s got to telemedicine and then
0:42:12 it’s come way down, not to pre-COVID levels, but way down.
0:42:17 A lot of this goes to how we pay for it and the fact that a lot of systems, doctors who
0:42:22 do it get paid half as opposed to seeing the patient in their office.
0:42:26 But we’ve also realized that we can do a lot of things out of the hospital.
0:42:29 So you’re seeing a lot of surgeries migrate out of the hospital.
0:42:34 You’re seeing more home care out of the hospital.
0:42:37 At the University of Pennsylvania, one of the things we ended up doing during COVID was
0:42:41 to go to patients’ houses and administer chemotherapy.
0:42:46 When I was training low these many years ago in the early 1990s, if you had told me, “We’re
0:42:50 going to give this chemotherapy that caused a lot of nausea and vomiting, we’re going
0:42:53 to give it at the patient’s home,” I would have said, “The psychiatric hospital, that’s
0:42:54 not far away.
0:42:56 Let’s take you over there.”
0:42:57 But that’s what we’ve been able to do.
0:43:02 Now, partly that’s because we have better drugs for nausea and vomiting, partially it’s because
0:43:08 we really understand how to do this and that’s a big, big advance.
0:43:12 Here’s why I’m really positive about telemedicine.
0:43:16 Twenty percent of our population lives in rural areas.
0:43:18 We’ve seen hospitals close there.
0:43:23 We’re going to have to get them access, not just to a primary care doc, but to specialists
0:43:26 that aren’t living nearby.
0:43:28 And telemedicine is going to be important.
0:43:34 Here again is another legacy of history that people don’t pay attention to.
0:43:38 Medical licensure and regulation is state-based.
0:43:41 That makes no sense in the modern era.
0:43:47 With Zoom, if you’re in South Dakota and you can get your treatment from Chicago or Pennsylvania
0:43:51 or New York, why should we have the licensure only in South Dakota?
0:43:56 We really need to get to the next level national licensure.
0:43:58 But states are jealous of their prerogatives.
0:44:01 They’re not going to give it up easily.
0:44:02 This is a problem in our country.
0:44:05 We have to move with the times.
0:44:06 We have to be more innovative.
0:44:12 Let me go back to administering chemo at home during COVID, which is really interesting.
0:44:16 Let me hear you speak a little bit about how cancer care and especially chemo have changed
0:44:18 over the past couple of decades.
0:44:23 But I want to frame that within a bigger question or maybe it’s just an observation, which is
0:44:24 the following.
0:44:26 There was an economics paper years ago.
0:44:29 I don’t know if you ever read it, and I’m curious to know what you think of the idea,
0:44:35 which is that the so-called war on cancer, which was begun, gosh, over 50 years ago now.
0:44:39 Some people claim it’s been nowhere near as successful as one might hope.
0:44:46 The paper argued that that argument is masking a big different trend, which is cardiovascular
0:44:53 care has become so much better that many, many, many people are not dying of the cardiovascular
0:44:57 diseases that would have killed them in an earlier generation and are living long enough
0:44:58 to get cancer.
0:45:01 I’m curious to know what you think of that framework, but I’d love you to just give us
0:45:05 the state of cancer care and especially chemo now.
0:45:09 Well, at one time, I might have been skeptical.
0:45:15 Yes, we began this under Richard Nixon in the early 1970s, and it’s now more than 50
0:45:16 years.
0:45:22 All of the progress we’ve made over the last decade or two really go back to the research
0:45:28 that was started of the war on cancer and accelerated by the human genome project and
0:45:35 figuring out where the defects are in the DNA that lead to cancer, being able now to
0:45:38 target those specific defects.
0:45:41 All of that took a long time.
0:45:45 We’ve done a marvelous job at cutting cancer death rate.
0:45:50 That means that for everyone who gets cancer, fewer people die, but I do think we’ve had
0:45:58 a huge improvement in cardiac disease, multiple factors, a lot of lifestyle factors, humongous
0:46:05 drop in smoking, changes in diet, so we are more aware of cholesterol, people on statins,
0:46:11 incredible breakthrough, drug, not to mention all the other intervention stents and things
0:46:12 like that.
0:46:16 So, we have had huge progress in cardiovascular disease.
0:46:22 Now, having said all of that, we’re seeing a big increase in younger people getting cancers
0:46:25 which we thought they never should get, like colon cancer.
0:46:32 I had a very dear friend die in her early 40s from a humongous colon cancer.
0:46:38 When I was training in the 1990s, we never would have seen that, never.
0:46:39 What do you think is going on?
0:46:40 No one knows for sure.
0:46:42 Here are some possibilities.
0:46:49 We’ve changed the human microbiome in the gut, the bacteria by eating the wrong things.
0:46:56 For processed foods that causes obesity, it also causes a decrease in the variety of bacteria
0:47:00 we have and a decrease in the good bacteria.
0:47:05 That micro environment that affects cells created by the bacteria in our gut is probably
0:47:07 critically important.
0:47:15 If you don’t eat fermented foods like yogurt, kimchi, if you don’t eat a lot of fiber that
0:47:21 comes with fruits and vegetables, you’re dramatically changing that micro-biome.
0:47:22 That’s a hypothesis.
0:47:26 Let’s be clear with your audience, it’s a hypothesis.
0:47:33 So, Zeke, I understand you had a birthday recently, yes, 67 years old, is that true?
0:47:34 Oh boy.
0:47:39 Your spies, you worked for the CIA recently?
0:47:41 Can you confirm, though, you’re 67 years old.
0:47:44 I can confirm I’m 67 years old.
0:47:50 I know that every year you set for yourself something new, radically new to do.
0:47:54 You’ve become a chocolate maker, you’ve become a serious cyclist.
0:47:57 Tell me one thing that’s on your list for the future.
0:47:58 I’ll tell you a trivial thing.
0:47:59 I want to make honey.
0:48:01 I thought bees did that.
0:48:03 We’ve just planted a lot of trees.
0:48:06 We have a lot of bees that love our lavender plants.
0:48:07 So that’s a sort of hobby.
0:48:12 But I would say, seriously, one of my life goals is, I’m a first-born and I think one
0:48:20 of my deficits, if I had to put it this way, is I can be slightly not sufficiently empathetic.
0:48:22 I can be a little too dismissive.
0:48:25 And I would like to improve those.
0:48:30 I’d like to be more empathetic to the people around me and decrease the sarcasm in my
0:48:31 responses.
0:48:35 Now, why do you care about that at this stage in life?
0:48:37 I think it makes a difference to people.
0:48:43 I’ve become more interested in how people get to where they are and also more interested
0:48:48 in what changes they’ve made, what challenges they’ve confronted, how they’ve overcome
0:48:49 their challenges.
0:48:51 And I’d like to do more of that.
0:48:57 My father-in-law makes me bookmarks, the most recent bookmark for my 67th birthday he wrote
0:49:00 on the bookmark, allergic to idiots.
0:49:05 I am allergic to idiots, but I had in the past confused that with not taking an interest
0:49:10 in people and that was probably a result of being first-born, having my brothers constantly
0:49:11 attack me, whatever.
0:49:15 Can I say all of you brothers complain about each other in exactly the same way as if birth
0:49:18 order was irrelevant?
0:49:23 But I would say being curious about the lives of other people, it’s led me to read a lot
0:49:27 of biographies and understand the challenges people have overcome.
0:49:32 I’ve read a recent biography of Hubert Humphrey and the kinds of challenges he confronted,
0:49:34 but the fact that everyone liked him.
0:49:39 That’s an interesting and very important quality, that you could be open to people, you could
0:49:44 be empathetic of people, even people who you disagreed with so much that they actually
0:49:47 liked you, we don’t have enough of that in our society.
0:49:52 And so one of the things you ask me, you know, I’m Jewish and the new year is coming up,
0:49:58 that I’m committing myself to is more empathy and less sarcasm in my voice, but also making
0:50:02 honey, making life sweet.
0:50:04 The late in life empathist, I love it.
0:50:07 And now I’m sure you get asked about this all the time and I’m sorry if it’s a pain
0:50:12 in the neck, but you did publish a piece in the Atlantic back in 2014, which got a lot
0:50:13 of attention.
0:50:17 Headline was why I hope to die at 75.
0:50:19 First of all, just rehearse the argument.
0:50:21 What was the point you were trying to make?
0:50:22 I believe it was a bit misunderstood.
0:50:25 Yeah, it’s not like I’m going to die at 75.
0:50:32 It’s that I would not take life prolonging treatments at 75, like cancer chemotherapies
0:50:34 or renal dialysis if my kidneys fail.
0:50:37 But you also said no more flu shots, for instance.
0:50:38 Right.
0:50:40 There are two things that have gotten under people’s skin.
0:50:47 One is vaccinations and the other is antibiotics that would readily cure a condition.
0:50:55 Now on the vaccines, I think COVID has somewhat changed my attitude on that because, you know,
0:50:59 you can get a shot and it would make a very big difference.
0:51:02 Why did you need the COVID vaccine to persuade you of that?
0:51:06 Wouldn’t what you just said describe just about all the vaccines that are commonly used?
0:51:10 Well, measles is not my big problem, you know, and diphtheria is not my big problem.
0:51:12 Thank you very much, Stephen.
0:51:16 If I somehow broke my hip, I would get that repaired.
0:51:18 I’m not force-wearing all medical care.
0:51:23 It was really about life saving, you know, people, oh, the golden years, all the advertisements
0:51:29 out there for Medicare Advantage health plans make the golden years look like I’m hiking
0:51:32 in Montana and beautiful vistas and all that.
0:51:33 That’s not what they’re like.
0:51:37 What happens for most people is they end up watching a lot more TV.
0:51:39 They tend to be homebound.
0:51:43 They get a lot of disabilities over time.
0:51:49 They’re not filled with the joys that everyone imagines if they’re going to get 10 more years.
0:51:53 The other thing is they’re also filled with a lot of cognitive decline.
0:51:55 Yes, it is true.
0:51:59 The rate of Alzheimer’s disease has actually gone down, but the total number of people
0:52:03 with Alzheimer’s gone up, I think the number is, and I haven’t checked this recently, by
0:52:07 80 years old, about 30% of people have some cognitive decline.
0:52:09 That’s a huge number.
0:52:10 So you want to get out while the getting’s good?
0:52:18 I see no reason in prolonging that if I’m not being creative, I’m not interacting.
0:52:23 I don’t watch TV, so I wouldn’t want to be spending my time watching TV, even good movies.
0:52:25 That seems like a very passive life.
0:52:29 I’m not a passive person, and I don’t think anyone wants or should want to be a passive
0:52:30 person.
0:52:36 But for all your optimism about intellect and technology generally, whether it’s AI, machine
0:52:42 learning, or just the way the brain can come up with things, who’s to say that all the
0:52:48 downsides that you see of aging won’t be mitigated to some degree by various technologies
0:52:52 and that maybe, heck, you could at 100 be doing things.
0:52:57 Now maybe you’d be doing them quasi-virtually, but do you entertain those kind of thoughts?
0:53:02 I entertain those thoughts, but I haven’t seen that actually be a reality.
0:53:09 I think people are delusional when they imagine, “I’ll be like I am now when I’m 90,” probably
0:53:10 not.
0:53:14 Maybe AI, regenerative medicine, maybe those things will happen, then I’ll reassess.
0:53:15 But they’re not happening now.
0:53:20 We’re seeing greater disabilities and people having a lot of cognitive decline.
0:53:23 I am not wild about that kind of life.
0:53:26 You have to ask yourself, “What is the purpose of my life?
0:53:27 Why am I living?
0:53:29 And how does that relate to age?”
0:53:33 Most people will say, if you just ask them, “Oh, I want quality over quantity,” but then
0:53:38 when they actually behave, they are taking quantity even when the quality of their life
0:53:40 is not what they actually want.
0:53:42 Of course I think my view is the right view.
0:53:45 I’ve spent a lot of time thinking about this, but I will tell you, Stephen, it’s a decade
0:53:48 of people writing to me.
0:53:51 About a third of people say, “Dr. Emmanuel, you’re 100 percent right.”
0:53:54 A third of people say, “Well, you’ve made me rethink.”
0:53:56 They don’t necessarily endorse my view.
0:54:01 If I’ve just made you rethink how you’re going to live your life and examine what you’re
0:54:03 living for, that’s a really good thing.
0:54:06 And a third of people think, “I’m off my rocker,” and maybe I am.
0:54:10 It’s quite a legacy, though, that you’ve made so many people rethink something as fundamental
0:54:11 as the end of their life.
0:54:16 I don’t want to pat myself on the back, but I don’t mind being what Socrates called
0:54:17 the Gadfly.
0:54:22 Part of what I do as a professor is challenge people about their views, and I want them
0:54:24 to rethink their views.
0:54:27 They might embrace their views wholeheartedly.
0:54:28 That’s fine.
0:54:30 As long as it’s, as Socrates says, an examined life.
0:54:35 As long as you can defend and justify where you’ve come down, that’s the place people
0:54:36 need to be.
0:54:38 And I hope everyone gets there.
0:54:40 I hope they think through, “What am I living for?
0:54:42 What good am I doing in this world?
0:54:45 Whose lives am I making better?”
0:54:49 In the end, that’s why we’re here.
0:54:54 My thanks to Zika Manual for a conversation that I found informative, challenging, occasionally
0:54:55 inspiring.
0:54:58 I’m curious to know how you felt.
0:54:59 Let me know.
0:55:02 Our email is radio@freakonomics.com.
0:55:08 Coming up next time on the show, another one-on-one conversation, this one with Adam Moss, who
0:55:12 is widely considered the best magazine editor of his generation.
0:55:17 He also happens to be my former editor and boss.
0:55:22 I learned a lot from Adam, especially how to be direct.
0:55:28 I just thought this was bullshit, and I thought it was bullshit over a long period of time.
0:55:30 That’s next time on the show.
0:55:35 Until then, take care of yourself and, if you can, someone else too.
0:55:37 Freakonomics Radio is produced by Stitcher and Renbud Radio.
0:55:43 You can find our entire archive on any podcast app also at Freakonomics.com, where we publish
0:55:46 transcripts and show notes.
0:55:48 This episode was produced by Zach Lipinski.
0:55:53 The Freakonomics Radio network staff also includes Alina Kulman, Augusta Chapman, Dalvin
0:55:58 Abouaji, Eleanor Osborne, Ellen Frankman, Elsa Hernandez, Gabriel Roth, Greg Rippen,
0:56:03 Jasmine Klinger, Jason Gambrell, Jeremy Johnston, John Schnarrs, Lyric Bowditch, Morgan Levy,
0:56:07 Neil Coruth, Rebecca Lee Douglas, Sarah Lilly, and Theo Jacobs.
0:56:13 Our theme song is Mr. Fortune by the Hitchhikers, and our composer is Luis Guerra.
0:56:14 As always, thank you for listening.
0:56:25 I know we have approximately 75 minutes I want to use every day on one of them, so we’ll
0:56:26 just get going.
0:56:29 Oh my god, I’m not sure I can talk that long.
0:56:31 Yeah, you can.
0:56:32 You caught me.
0:56:33 Alright.
0:56:45 The Freakonomics Radio network, the hidden side of everything.
0:56:48 (bright music)
0:56:50 you