ZERO GRACE/ZERO MALICE

Amazon's purchase of One Medical could speed up American healthcare

The U.S. healthcare industry is a 7-ton seal bleeding at sea. Predators are circling. Unearned margin: price increases relative to inflation without quality improvements. Amazon is the 11-foot megalodon with 7-inch teeth. Amazon is no longer circling... but attacking.

In 2020 dollars, per capita U.S. healthcare spending increased from $2,968 in 1980 to $12,531. The result is a massive industry with 13% of the nation's workers and a fifth of GDP.

Doctor No

In 40 years, healthcare has made progress. From 73.7 in 1980 to 78.8 in 2019, life expectancy rose (before Covid knocked it back down a bit). Pharmacological therapies have revolutionized, and genetic research is paying off. The financial return, improvement split by cost increases, is terrible. No country has expense rises like the U.S., and no one spends as much per capita as we do. Developed countries have longer life expectancies, healthier populations, and less economic hardship.

Two-thirds of U.S. personal bankruptcies are due to medical expenses and/or missed work. Mom or Dad getting cancer could bankrupt many middle-class American families. 40% of American adults delayed or skipped needed care due to cost. Every healthcare improvement seems to have a downside. Same pharmacological revolution that helped millions caused opioid epidemic. Our results are poor in many areas: The U.S. has a high infant mortality rate.

Healthcare is the second-worst retail industry in the country. Gas stations are #1. Imagine walking into a Best Buy to buy a TV and a Blue Shirt associate requests you fill out the same 14 pages of paperwork you filled out yesterday. Then you wait in a crowded room until they call you, 20 minutes after the scheduled appointment you were asked to arrive early for, to see the one person in the store who can talk to you about TVs, who has 10 minutes for you. The average emergency room wait time in New York is 6 hours and 10 minutes.

If it's bad for the customer, it's worse for the business. Physicians spend 27% of their time helping patients; 49% on EHRs. Documentation, order entry, billing, and inbox management. Spend a decade getting an M.D., then become a bureaucrat.

No industry better illustrates scale diseconomies. If we got the same return on healthcare spending as other countries, we'd all live to 100. We could spend less, live longer and healthier, and pay off the national debt in 15 years. U.S. healthcare is the worst ever.

What now? Competition is at the heart of capitalism, the worst system of its kind.

Priority Time

Amazon is buying One Medical for $3.9 billion. I think this deal will liberate society. Two years in, I think One Medical is great. When I got Covid, I pressed the One Medical symbol on my phone; a nurse practitioner prescribed Paxlovid and told me which pharmacies had it in stock.

Amazon enables the company's vision. One Medical's stock is down to $10 from $40 at the start of 2021. Last year, it lost $250 million and needs cash (Amazon has $60 billion). ONEM must grow. The service has 736,000 members. Half of U.S. households have Amazon Prime. Finally, delivery. One Medical is a digital health/physical office hybrid, but you must pick up medication at the pharmacy. Upgrade your Paxlovid delivery time after a remote consultation. Amazon's core competency means it'll happen. Healthcare speed and convenience will feel alien.

It's been a long, winding road to disruption. Amazon, JPMorgan, and Berkshire Hathaway formed Haven four years ago to provide better healthcare for their 1.5 million employees. It rocked healthcare stocks the morning of the press release, but folded in 2021.

Amazon Care is an employee-focused service. Home-delivered virtual health services and nurses. It's doing well, expanding nationwide, and providing healthcare for other companies. Hilton is Amazon Care's biggest customer. The acquisition of One Medical will bring 66 million Prime households capital, domain expertise, and billing infrastructure. Imagine:

"Alexa, I'm hot and my back hurts."

"Connecting you to a Prime doctor now."

Want to vs. Have to

I predicted Amazon entering healthcare years ago. Why? For the same reason Apple is getting into auto. Amazon's P/E is 56, double Walmart's. The corporation must add $250 billion in revenue over the next five years to retain its share price. White-label clothes or smart home products won't generate as much revenue. It must enter a huge market without scale, operational competence, and data skills.

Current Situation

Healthcare reform benefits both consumers and investors. In 2015, healthcare services had S&P 500-average multiples. The market is losing faith in public healthcare businesses' growth. Healthcare services have lower EV/EBITDA multiples than the S&P 500.

Amazon isn't the only prey-hunter. Walmart and Alibaba are starting pharmacies. Uber is developing medical transportation. Private markets invested $29 billion in telehealth last year, up 95% from 2020.

The pandemic accelerated telehealth, the immediate unlock. After the first positive Covid case in the U.S., services that had to be delivered in person shifted to Zoom... We lived. We grew. Video house calls continued after in-person visits were allowed. McKinsey estimates telehealth visits are 38 times pre-pandemic levels. Doctors adopted the technology, regulators loosened restrictions, and patients saved time. We're far from remote surgery, but many patient visits are unnecessary. A study of 40 million patients during lockdown found that for chronic disease patients, online visits didn't affect outcomes. This method of care will only improve.

Amazon's disruption will be significant and will inspire a flood of capital, startups, and consumer brands. Mark Cuban launched a pharmacy that eliminates middlemen in January. Outcome? A 90-day supply of acid-reflux medication costs $17. Medicare could have saved $3.6 billion by buying generic drugs from Cuban's pharmacy. Other apex predators will look at different limbs of the carcass for food. Nike could enter healthcare via orthopedics, acupuncture, and chiropractic. LVMH, L'Oréal, and Estée Lauder may launch global plastic surgery brands. Hilton and Four Seasons may open hospitals. Lennar and Pulte could build "Active Living" communities that Nana would leave feet first, avoiding the expense and tragedy of dying among strangers.

Risks

Privacy matters: HIV status is different from credit card and billing address. Most customers (60%) feel fine sharing personal health data via virtual technologies, though. Unavoidable. 85% of doctors believe data-sharing and interoperability will become the norm. Amazon is the most trusted tech company for handling personal data. Not Meta: Amazon.

What about antitrust, then?

Amazon should be required to spin off AWS and/or Amazon Fulfillment and banned from promoting its own products. It should be allowed to acquire hospitals. One Medical's $3.9 billion acquisition is a drop in the bucket compared to UnitedHealth's $498 billion market valuation.

Antitrust enforcement shouldn't assume some people/firms are good/bad. It should recognize that competition is good and focus on making markets more competitive in each deal. The FTC should force asset divestitures in e-commerce, digital marketing, and social media. These companies can also promote competition in a social ill.

U.S. healthcare makes us fat, depressed, and broke. Competition has produced massive value and prosperity across most of our economy.

Dear Amazon … bring it.

My colleague Ilana Ovental and I examined pandemic media coverage of education at the end of last year. That analysis examined coverage changes. We tracked K-12 topic attention over the previous two decades using Lexis Nexis. See the results here.

I was struck by how cleanly the past two decades can be divided up into three (or three and a half) eras of school reform—a framing that can help us comprehend where we are and how we got here. In a time when epidemic, political unrest, frenetic news cycles, and culture war can make six months seem like a lifetime, it's worth pausing for context.

If you look at the peaks in the above graph, the 21st century looks to be divided into periods. The decade-long rise and fall of No Child Left Behind began during the Bush administration. In a few years, NCLB became the dominant K-12 framework. Advocates and financiers discussed achievement gaps and measured success with AYP.

NCLB collapsed under the weight of rigorous testing, high-stakes accountability, and a race to the bottom by the Obama years. Obama's Race to the Top garnered attention, but its most controversial component, the Common Core State Standards, rose quickly.

Academic standards replaced assessment and accountability. New math, fiction, and standards were hotly debated. Reformers and funders chanted worldwide benchmarking and systems interoperability.

We went from federally driven testing and accountability to government encouraged/subsidized/mandated (pick your verb) reading and math standardization. Last year, Checker Finn and I wrote The End of School Reform? The 2010s populist wave thwarted these objectives. The Tea Party, Occupy Wall Street, Black Lives Matter, and Trump/MAGA all attacked established institutions.

Consequently, once the Common Core fell, no alternative program emerged. Instead, school choice—the policy most aligned with populist suspicion of institutional power—reached a half-peak. This was less a case of choice erupting to prominence than of continuous growth in a vacuum. Even with Betsy DeVos' determined, controversial efforts, school choice received only half the media attention that NCLB and Common Core did at their heights.

Recently, culture clash-fueled attention to race-based curriculum and pedagogy has exploded (all playing out under the banner of critical race theory). This third, culture war-driven wave may not last as long as the other waves.

Even though I don't understand it, the move from slow-building policy debate to fast cultural confrontation over two decades is notable. I don't know if it's cyclical or permanent, or if it's about schooling, media, public discourse, or all three.

One final thought: After doing this work for decades, I've noticed how smoothly advocacy groups, associations, and other activists adapt to the zeitgeist. In 2007, mission statements focused on accomplishment disparities. Five years later, they promoted standardization. Language has changed again.

Part of this is unavoidable and healthy. Chasing currents can also make companies look unprincipled, promote scepticism, and keep them spinning the wheel. Bearing in mind that these tides ebb and flow may give educators, leaders, and activists more confidence to hold onto their values and pause when they feel compelled to follow the crowd.

Homeownership isn't the only life pattern.

Want to irritate people?

My party trick is to say I used to own a house but no longer do.

I no longer wish to own a home, not because I lost it or because I'm moving.

It was a long-term plan. It was more deliberate than buying a home. Many people are committed for this reason.

Poppycock.

Anyone who told me that owning a house (or striving to do so) is a must is wrong.

Because, URGH.

One pattern for life is to own a home, but there are millions of others.

You can afford to buy a home? Go, buddy.

You think you need 1,000 square feet (or more)? You think it's non-negotiable in life?

Nope.

It's insane that society forces everyone to own real estate, regardless of income, wants, requirements, or situation. As if this trade brings happiness, stability, and contentment.

Take it from someone who thought this for years: drywall isn't happy. Living your way brings contentment.

That's in real estate. It may also be renting a small apartment in a city that makes your soul sing, but you can't afford the downpayment or mortgage payments.

Living or traveling abroad is difficult when your life savings are connected to something that eats your money the moment you sign.

#vanlife, which seems like torment to me, makes some people feel alive.

I've seen co-living, vacation rental after holiday rental, living with family, and more work.

Insisting that home ownership is the only path in life is foolish and reduces alternative options.

How little we question homeownership is a disgrace.

No one challenges a homebuyer's motives. We congratulate them, then that's it.

When you offload one, you must answer every question, even if you have a loose screw.

• Why do you want to sell?

• Do you have any concerns about leaving the market?

• Why would you want to renounce what everyone strives for?

• Why would you want to abandon a beautiful place like that?

• Why would you mismanage your cash in such a way?

• But surely it's only temporary? RIGHT??

Incorrect questions. Buying a property requires several inquiries.

• The typical American has $4500 saved up. When something goes wrong with the house (not if, it’s never if), can you actually afford the repairs?

• Are you certain that you can examine a home in less than 15 minutes before committing to buying it outright and promising to pay more than twice the asking price on a 30-year 7% mortgage?

• Are you certain you're ready to leave behind friends, family, and the services you depend on in order to acquire something?

• Have you thought about the connotation that moving to a suburb, which more than half of Americans do, means you will be dependent on a car for the rest of your life?

Plus:

Are you sure you want to prioritize home ownership over debt, employment, travel, raising kids, and daily routines?

Homeownership entails that. This ex-homeowner says it will rule your life from the time you put the key in the door.

This isn't questioned. We don't question enough. The holy home-ownership grail was set long ago, and we don't challenge it.

Many people question after signing the deeds. 70% of homeowners had at least one regret about buying a property, including the expense.

Exactly. Tragic.

Homes are different from houses

We've been fooled into thinking home ownership will make us happy.

Some may agree. No one.

Bricks and brick hindered me from living the version of my life that made me most comfortable, happy, and steady.

I'm spending the next month in a modest apartment in southern Spain. Even though it's late November, today will be 68 degrees. My spouse and I will soon meet his visiting parents. We'll visit a Sherry store. We'll eat, nap, walk, and drink Sherry. Writing. Jerez means flamenco.

That's my home. This is such a privilege. Living a fulfilling life brings me the contentment that buying a home never did.

I'm happy and comfortable knowing I can make almost all of my days good. Rejecting home ownership is partly to blame.

I'm broke like most folks. I had to choose between home ownership and comfort. I said, I didn't find them together.

Feeling at home trumps owning brick-and-mortar every day.

The following is the reality of what it's like to turn the American Dream around.

Leaving the housing market.

Sometimes I wish I owned a home.

I miss having my own yard and bed. My kitchen, cookbooks, and pizza oven are missed.

But I rarely do.

Someone else's life plan pushed home ownership on me. I'm grateful I figured it out at 35. Many take much longer, and some never understand homeownership stinks (for them).

It's confusing. People will think you're dumb or suicidal.

If you read what I write, you'll know. You'll realize that all you've done is choose to live intentionally. Find a home beyond four walls and a picket fence.

Miss? As I said, they're not home. If it were, a pizza oven, a good mattress, and a well-stocked kitchen would bring happiness.

No.

If you can afford a house and desire one, more power to you.

There are other ways to discover home. Find calm and happiness. For fun.

For it, look deeper than your home's foundation.

Consider yourself lucky if your last FAANG interview was rejected.

FAANG—Facebook, Apple, Amazon, Netflix, Google

(I know its manga now, but watch me not care)

These big companies offer many benefits.

1. large salaries and benefits

2. Prestige

3. high expectations for both you and your coworkers.

However, these jobs may have major drawbacks that only become apparent when you're thrown to the wolves, so it's up to you whether you see them as drawbacks or opportunities.

I know most college graduates start working at big tech companies because of their perceived coolness.

I've worked in these companies for years and can tell you what to expect if you get a job here.

Little fish in a vast ocean

The most obvious. Most billion/trillion-dollar companies employ thousands.

You may work on a small, unnoticed product part.

Directors and higher will sometimes make you redo projects they didn't communicate well without respecting your time, talent, or will to work on trivial stuff that doesn't move company needles.

Peers will only say, "Someone has to take out the trash," even though you know company resources are being wasted.

The power imbalance is frustrating.

What you can do about it

Know your WHY. Consider long-term priorities. Though riskier, I stayed in customer-facing teams because I loved building user-facing products.

This increased my impact. However, if you enjoy helping coworkers build products, you may be better suited for an internal team.

I told the Directors and Vice Presidents that their actions could waste Engineering time, even though it was unpopular. Some were receptive, some not.

I kept having tough conversations because they were good for me and the company.

However, some of my coworkers praised my candor but said they'd rather follow the boss.

An outdated piece of technology can take years to update.

Apple introduced Swift for iOS development in 2014. Most large tech companies adopted the new language after five years.

This is frustrating if you want to learn new skills and increase your market value.

Knowing that my lack of Swift practice could hurt me if I changed jobs made writing verbose Objective C painful.

What you can do about it

1. Work on the new technology in side projects; one engineer rewrote the Lyft app in Swift over the course of a weekend and promoted its adoption throughout the entire organization.

2. To integrate new technologies and determine how to combine legacy and modern code, suggest minor changes to the existing codebase.

Most managers spend their entire day in consecutive meetings.

After their last meeting, the last thing they want is another meeting to discuss your career goals.

Sometimes a manager has 15-20 reports, making it hard to communicate your impact.

Misunderstandings and stress can result.

Especially when the manager should focus on selfish parts of the team. Success won't concern them.

What you can do about it

1. Tell your manager that you are a self-starter and that you will pro-actively update them on your progress, especially if they aren't present at the meetings you regularly attend.

2. Keep being proactive and look for mentorship elsewhere if you believe your boss doesn't have enough time to work on your career goals.

3. Alternately, look for a team where the manager has more authority to assist you in making career decisions.

After a certain point, company loyalty can become quite harmful.

Because big tech companies create brand loyalty, too many colleagues stayed in unhealthy environments.

When you work for a well-known company and strangers compliment you, it's fun to tell your friends.

Work defines you. This can make you stay too long even though your career isn't progressing and you're unhappy.

Google may become your surname.

Workplaces are not families.

If you're unhappy, don't stay just because they gave you the paycheck to buy your first home and make you feel like you owe your life to them.

Many employees stayed too long. Though depressed and suicidal.

What you can do about it

1. Your life is not worth a company.

2. Do you want your job title and workplace to be listed on your gravestone? If not, leave if conditions deteriorate.

3. Recognize that change can be challenging. It's difficult to leave a job you've held for a number of years.

4. Ask those who have experienced this change how they handled it.

You still have a bright future if you were rejected from FAANG interviews.

Rejections only lead to amazing opportunities. If you're young and childless, work for a startup.

Companies may pay more than FAANGs. Do your research.

Ask recruiters and hiring managers tough questions about how the company and teams prioritize respectful working hours and boundaries for workers.

I know many 15-year-olds who have a lifelong dream of working at Google, and it saddens me that they're chasing a name on their resume instead of excellence.

This article is not meant to discourage you from working at these companies, but to share my experience about what HR/managers will never mention in interviews.

Read both sides before signing the big offer letter.

Fixing problems isn't enough.

Numerous articles and how-to guides on value propositions focus on fixing consumer concerns.

Contrary to popular opinion, addressing customer pain rarely suffices. Win your market category too.

Core Value Statement

Value proposition usually means a product's main value.

Its how your product solves client problems. The product's core.

Answering these questions creates a relevant core value proposition:

• What tasks is your customer trying to complete? (Jobs for clients)

• How much discomfort do they feel while they perform this? (pains)

• What would they like to see improved or changed? (gains)

After that, you create products and services that alleviate those pains and give value to clients.

Value Proposition by Category

Your product belongs to a market category and must follow its regulations, regardless of its value proposition.

Creating a new market category is challenging. Fitting into customers' product perceptions is usually better than trying to change them.

New product users simplify market categories. Products are labeled.

Your product will likely be associated with a collection of products people already use.

Example: IT experts will use your communication and management app.

If your target clients think it's an advanced mail software, they'll compare it to others and expect things like:

• comprehensive calendar

• spam detectors

• adequate storage space

• list of contacts

• etc.

If your target users view your product as a task management app, things change. You can survive without a contact list, but not status management.

Find out what your customers compare your product to and if it fits your value offer. If so, adapt your product plan to dominate this market. If not, try different value propositions and messaging to put the product in the right context.

Finished Value Proposition

A comprehensive value proposition is when your solution addresses user problems and wins its market category.

Addressing simply the primary value proposition may produce a valuable and original product, but it may struggle to cross the chasm into the mainstream market. Meeting expectations is easier than changing views.

Without a unique value proposition, you will drown in the red sea of competition.

To conclude:

1. Find out who your target consumer is and what their demands and problems are.

2. To meet these needs, develop and test a primary value proposition.

3. Speak with your most devoted customers. Recognize the alternatives they use to compare you against and the market segment they place you in.

4. Recognize the requirements and expectations of the market category.

5. To meet or surpass category standards, modify your goods.

Great products solve client problems and win their category.

In simple terms, you probably don’t.

But try. Grandma didn't grow up with Facebook, but she eventually joined.

Perhaps the fear of being isolated outweighed the discomfort of learning the technology.

Grandmas are Facebook likers, sharers, and commenters.

There’s no stopping her.

Not even NFTs. Web3 is currently very complex.

It's difficult to explain what NFTs are, how they work, and why we might use them.

Three explanations.

1. Everything will be ours to own, both physically and digitally.

Why own something you can't touch? What's the point?

Blockchain technology proves digital ownership.

Untouchables need ownership proof. What?

Digital assets reduce friction, save time, and are better for the environment than physical goods.

Many valuable things are intangible. Feeling like your favorite brands. You'll pay obscene prices for clothing that costs pennies.

Secondly, NFTs Are Contracts. Agreements Have Value.

Blockchain technology will replace all contracts and intermediaries.

Every insurance contract, deed, marriage certificate, work contract, plane ticket, concert ticket, or sports event is likely an NFT.

We all have public wallets, like Grandma's Facebook page.

3. Your NFT Purchases Will Be Visible To Everyone.

Everyone can see your public wallet. What you buy says more about you than what you post online.

NFTs issued double as marketing collateral when seen on social media.

While I doubt Grandma knows who Snoop Dog is, imagine him or another famous person holding your NFT in his public wallet and the attention that could bring to you, your company, or brand.

This Technical Section Is For You

The NFT is a contract; its founders can add value through access, events, tuition, and possibly royalties.

Imagine Elon Musk releasing an NFT to his network. Or yearly business consultations for three years.

Christ-alive.

It's worth millions.

These determine their value.

No unsuspecting schmuck willing to buy your hot potato at zero. That's the trend, though.

Overpriced NFTs for low-effort projects created a bubble that has burst.

During a market bubble, you can make money by buying overvalued assets and selling them later for a profit, according to the Greater Fool Theory.

People are struggling. Some are ruined by collateralized loans and the gold rush.

Finances are ruined.

It's uncomfortable.

The same happened in 2018, during the ICO crash or in 1999/2000 when the dot com bubble burst. But the underlying technology hasn’t gone away.