In this episode of A Moment in Health, Dr. Ashish Jha highlights a 24% decline in telehealth visits for Medicare beneficiaries following the October 1 government shutdown, driven by the sudden expiration of Medicare’s authority to pay for telehealth. He reviews a new JAMA randomized controlled trial on caffeinated coffee and atrial fibrillation. Dr. Stephanie Psaki, Distinguished Senior Fellow at the Brown School of Public Health, joins to explain why declining fertility rates around the world matter and why supporting people’s family planning choices should be a core public health and policy priority.

Dr. Jha discusses:

• Medicare Telehealth Flexibilities at Risk with Government Shutdown — Center for Advancing Health Policy Through Research
• Caffeinated Coffee Consumption or Abstinence to Reduce Atrial Fibrillation — JAMA
• The Real Way to Boost Birth Rates — TIME

About the Guest

Dr. Stephanie Psaki is a distinguished senior fellow at the Brown University School of Public Health and served as Special Assistant to the President and U.S. Coordinator for Global Health Security at the National Security Council.

About the Host

Dr. Ashish K. Jha is the dean of the Brown University School of Public Health.

Music by Katherine Beggs, additional music by Lulu West and Maya Polsky

Hey everybody. Ashish Jha here from a sunny but cold, almost winter like cold day in Providence, Rhode Island. Welcome back to another episode of a moment in health where we're going to talk about a data point, discuss the study and answer a question. So the data point of the Week is 24% that's the reduction the drop in telehealth visits since October 120, 25 now what happened on October 120, 25 Well, the government shut down, and there's a new study out today by colleagues here at the Brown School of Public Health, Atif mehotra and Michael Barnett and others, that looked at what happened to telehealth visits for Medicare beneficiaries after the government shutdown, and what they find is there's a 24% reduction in telehealth visits for seniors. Now you may be saying, oh, what does a government shutdown have anything to do with telehealth visits? I'll tell you what it is the authority to pay for telehealth visits by Medicare also expired on October 1, and because of the government shutdown, because there was no deal on the budget, Medicare could no longer pay for telehealth, and you saw a pretty substantial decline. Let me make one more point. When governments shut down, the most visible stuff is, you know, TSA workers now getting paid. Air traffic controllers obviously SNAP benefits. There's a whole bunch of stuff that's very visible to people, but there's, there are hundreds of other things that the government does that are actually quite essential that also get harmed during government shutdowns. One of them is just paying for telehealth visits. And so a lot of seniors who wanted to be able to see their doctor through a telehealth visit weren't able to, either they meant they had to get in a car and go do a personal visit, or didn't see anybody at all. That is real harm. And one more reminder that government shutdowns are not great for the health of the American people. Okay, so that's your data point for the week, 24% let's go

to the study of the week. The study of the week comes from JAMA, and it's called caffeine, caffeinated coffee consumption, or abstinence to reduce atrial fibrillation. The decaf randomized control trial. This was a randomized control trial that looked at whether drinking coffee, caffeinated coffee, not decaf, but had any impact on recurrence for atrial fibrillation. And what they found, to everybody's surprise, is that drinking coffee did not increase your risk of getting atrial fibrillation. It actually reduced it a little bit. So let me take a minute and explain why this is so interesting and fascinating, and why I personally am very excited about this study. So first of all, there's just a ton of data out there that coffee is good for you. Now, almost all that data is observational, meaning not randomized trials, but because I happen to love coffee, I will say I'm partial to that data. I like that data because it sort of reinforces my pre existing beliefs. But the skeptic in me knows that we've got to actually see randomized trial data before we start making any recommendations. One area where I have recommended to people that they avoid coffee is if they have atrial fibrillation, because it's a cardiac arrhythmia, and it stands to reason that coffee drinking would make that worse. However, this is why you need to do the randomized trial. There was a really nice randomized trial published in a recent issue of Jama that basically looked at, if you could randomize people to caffeinated coffee versus not, would it actually make your heart arrhythmia worse? And to my surprise, and to I think the surprise of probably everybody who's been seeing this study, what they found was that people who actually drank coffee, not talking about massive amounts, probably one to two cups a day, but people who drank coffee actually had slightly lower levels of recurrence of atrial fibrillation. It doesn't mean that if somebody has cardiac arrhythmias, you

should tell them to start drinking more coffee, but if they drink one to two cups of coffee a day, it's not a big deal. It's not going to harm them. More evidence that coffee is fine and you should enjoy coffee if that's what you enjoy drinking. All right. So that is your study of the week,

all right. And now for the question of the week and for the question of the week, we have our first repeat expert back with us, Stephanie Psaki, who's a senior fellow here at Brown School Public Health. Stephanie, thanks so much for coming back on the podcast. Thanks for having me. All right, so this time, I have a very different question than the one I asked last time. Last time it was about preparedness and security. This is about babies. You've been writing about the fact that you believe that the declining fertility rate that we're seeing around the world is a problem, and you've been writing about ideas for how to turn that around. But the question I have for you is actually very straightforward, in a world of 8 billion people, why is decline? Finding fertility a problem. What if we have fewer people in the world? Why is that a problem? Help us understand why this matters?

Sure. So let me give three reasons, I think, two that are kind of important at the national level, and one that's more broadly important that we should care about if we work in public health. So at the national level. You know, theoretically, what we think about is the economic impact. So in economies, generally speaking, workers contribute to the economy. They put money into the economy, and then what we call dependence, which is elderly or children, withdraw from the economy. Obviously, that's an over generalization, but we need people to be contributing to the economy and paying taxes. So the concern is that when you have population decline, eventually you hit a point where you have an aging population that is withdrawing from the economy, specifically government benefits, and you don't have enough workers that are paying into that system. So you end up with an economic challenge, one that, you know, many have been concerned about for the Social Security system in the United States. So that's kind of a theoretical economic problem, but one that a lot of countries are facing. Yeah, I think also at a national level. And we recently traveled to Japan and South Korea, which are two countries that have some of the lowest fertility levels in the world, Korea in particular, and you start to see social impacts of very low fertility and kind of broader national security and civil society impacts. So in Japan, they don't have enough young people to enlist in the military. You start to see communities where schools are closing because there aren't enough children to attend the schools, which then means the families that do have children don't have anywhere to send their kids, and everyone has to concentrate in the cities. And you start to see kind of a cultural shift away from supporting and accommodating families, because it just becomes a rare and a rare experience, and it makes it more difficult for people who do want children to then

have children. So I think those are two and, you know, those are two consequences, the first two that we really are already seeing in a number of countries around the world, I would say the third reason, and maybe the one that you know, as someone who has a background in demography and reproductive health, I care about the most, is that people should be able to make choices about whether and when to have children, and what we're seeing in data from all over the world, including in the United States, is that there are many people who want to have children and are not having the children they want. And then the biggest reason why they are not is financial. They can't afford to have the family that they want because housing is too expensive, child care is too expensive. They have unstable jobs. So I think from a public health perspective and just a policy perspective, we should want to create an environment where everyone is able to have the family they want, whether that includes children or no children.

Got it great. So there's some economic issues. There's sort of these broader societal things, but fundamentally, the fact is that we we should be promoting societies where people get to decide how big a family they want, and enable that to happen. Fantastic. That's super helpful. One last thing I wonder that I've often thought about is, do societies with more kids? Are they more forward, looking forward leaning on a personal note, when I first had kids, like my whole perspective on life changed, and I started thinking in a very different way about the long term health and well being of our country. Do you feel like that might have that has some effect, or do you? Do you think that's too theoretical, without much evidence? Yeah.

I mean, there's certainly, as you say, there's a lot of theory that you want younger workers because they tend to drive innovation in the workplace. But I think, you know, even if you look in the US, if you ask the youngest generation that's kind of entering childbearing, what the considerations are? One of the top considerations they name is climate change. They are the generation that, more than any of the older generations will have to deal with the consequences of climate change, and they worry about how to solve that problem. So you really want those people to have children and be teaching their children and equipping their children with the skills to address some of the biggest challenges we face.

Awesome. All right. Stefanie Saki, thanks so much for coming back on the podcast. I

really appreciate it. Thanks for having me.

And there you have it, another episode of a moment in health where we talked about one data point, 24% that's the reduction in telehealth visits for seniors, for Medicare beneficiaries because of the government shutdown. We talked about one study. We talked about a randomized trial of caffeine consumption coffee in patients with atrial fibrillation. It's kind of a heart rhythm. And this study found, to my surprise, pleasant surprise, since I'm very pro coffee, that, in fact, drinking caffeine did not increase the risk of recurrent atrial fibrillation. So that's good. More evidence, more reason to think that drinking coffee is just fine. And then we. Talk to Stephanie Psaki, the first guest we've had back on the show, on a totally different question than we talked to her about last time, and it was about, why should you care about societies having fewer kids? I mean, what we know is that there's been a drop in in fertility around the world, and a large number of countries now are below replacement rates, and that means you're gonna start seeing shrinking populations. There are a lot of people who are a lot of people who are like, hey, that's good news. We need fewer humans. I totally disagree. And Stefanie, actually, I think, made out a very compelling set of cases. One is that from a robust economy, it is good to have young people. They do power the economy. They work, and they actually help support both kids and older Americans or older people. The second is when the number of kids drop substantially. Societies change in very substantial ways. It's hard to sustain schools in rural areas. It's hard to have large parts of our society functioning because there's no young people around. We've seen in places like Japan and Korea substantial declines in their military, because you need young people to go into the military and a lot of other things as well. So that is a second and then the third point she made, which actually liked a lot,

was that if it was just about choice, people choosing not to have kids because they don't want to, we could have a debate about that. But what we're seeing in country after country is lots of people are having fewer kids than they would like, because the policy environment actually makes it very hard for people to have kids, because kids are expensive and societies don't support them enough. So that is another compelling reason. My personal view is those are all really good reasons. I also think societies with a lot of young people are dynamic, innovative and we and it's nice to have more young people around and kids around and young people around. So I'm pro having kids for that reason as well. All right, thanks so much for listening, and I will be back next week with another episode of a moment in health. We'll talk data, we'll talk study, we'll answer a question. You.