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.

I was entering tens of millions of records per hour when I first published Slonik PostgreSQL client for Node.js. The data being entered was usually flat, making it straightforward to use INSERT INTO ... SELECT * FROM unnset() pattern. I advocated the unnest approach for inserting rows in groups (that was part I).

However, today I’ve found a better way: jsonb_to_recordset.

jsonb_to_recordset expands the top-level JSON array of objects to a set of rows having the composite type defined by an AS clause.

jsonb_to_recordset allows us to query and insert records from arbitrary JSON, like unnest. Since we're giving JSON to PostgreSQL instead of unnest, the final format is more expressive and powerful.

SELECT *
FROM json_to_recordset('[{"name":"John","tags":["foo","bar"]},{"name":"Jane","tags":["baz"]}]')
AS t1(name text, tags text[]);
 name |   tags
------+-----------
 John | {foo,bar}
 Jane | {baz}
(2 rows)

Let’s demonstrate how you would use it to insert data.

Inserting data using json_to_recordset

Say you need to insert a list of people with attributes into the database.

const persons = [
  {
    name: 'John',
    tags: ['foo', 'bar']
  },
  {
    name: 'Jane',
    tags: ['baz']
  }
];

You may be tempted to traverse through the array and insert each record separately, e.g.

for (const person of persons) {
  await pool.query(sql`
    INSERT INTO person (name, tags)
    VALUES (
      ${person.name},
      ${sql.array(person.tags, 'text[]')}
    )
  `);
}

It's easier to read and grasp when working with a few records. If you're like me and troubleshoot a 2M+ insert query per day, batching inserts may be beneficial.

What prompted the search for better alternatives.

Inserting using unnest pattern might look like this:

await pool.query(sql`
  INSERT INTO public.person (name, tags)
  SELECT t1.name, t1.tags::text[]
  FROM unnest(
    ${sql.array(['John', 'Jane'], 'text')},
    ${sql.array(['{foo,bar}', '{baz}'], 'text')}
  ) AS t1.(name, tags);
`);

You must convert arrays into PostgreSQL array strings and provide them as text arguments, which is unsightly. Iterating the array to create slices for each column is likewise unattractive.

However, with jsonb_to_recordset, we can:

await pool.query(sql`
  INSERT INTO person (name, tags)
  SELECT *
  FROM jsonb_to_recordset(${sql.jsonb(persons)}) AS t(name text, tags text[])
`);

In contrast to the unnest approach, using jsonb_to_recordset we can easily insert complex nested data structures, and we can pass the original JSON document to the query without needing to manipulate it.

In terms of performance they are also exactly the same. As such, my current recommendation is to prefer jsonb_to_recordset whenever inserting lots of rows or nested data structures.