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.

Japan's startup challenge: 7 reasons

Every day, another Silicon Valley business is bought for a billion dollars, making its founders rich while growing the economy and improving consumers' lives.

Google, Amazon, Twitter, and Medium dominate our daily lives. Tesla automobiles and Moderna Covid vaccinations.

The startup movement started in Silicon Valley, California, but the rest of the world is catching up. Global startup buzz is rising. Except Japan.

644 of CB Insights' 1170 unicorns—successful firms valued at over $1 billion—are US-based. China follows with 302 and India third with 108.

Japan? 6!

1% of US startups succeed. The third-largest economy is tied with small Switzerland for startup success.

Mexico (8), Indonesia (12), and Brazil (12) have more successful startups than Japan (16). South Korea has 16. Yikes! Problem?

Why Don't Startups Exist in Japan More?

Not about money. Japanese firms invest in startups. To invest in startups, big Japanese firms create Silicon Valley offices instead of Tokyo.

Startups aren't the issue either. Local governments are competing to be Japan's Shirikon Tani, providing entrepreneurs financing, office space, and founder visas.

Startup accelerators like Plug and Play in Tokyo, Osaka, and Kyoto, the Startup Hub in Kobe, and Google for Startups are many.

Most of the companies I've encountered in Japan are either local offices of foreign firms aiming to expand into the Japanese market or small businesses offering local services rather than disrupting a staid industry with new ideas.

There must be a reason Japan can develop world-beating giant corporations like Toyota, Nintendo, Shiseido, and Suntory but not inventive startups.

Culture, obviously. Japanese culture excels in teamwork, craftsmanship, and quality, but it hates moving fast, making mistakes, and breaking things.

If you have a brilliant idea in Silicon Valley, quit your job, get money from friends and family, and build a prototype. To fund the business, you approach angel investors and VCs.

Most non-startup folks don't aware that venture capitalists don't want good, profitable enterprises. That's wonderful if you're developing a solid small business to consult, open shops, or make a specialty product. However, you must pay for it or borrow money. Venture capitalists want moon rockets. Silicon Valley is big or bust. Almost 90% will explode and crash. The few successes are remarkable enough to make up for the failures.

Silicon Valley's high-risk, high-reward attitude contrasts with Japan's incrementalism. Japan makes the best automobiles and cleanrooms, but it fails to produce new items that grow the economy.

Changeable? Absolutely. But, what makes huge manufacturing enterprises successful and what makes Japan a safe and comfortable place to live are inextricably connected with the lack of startups.

Barriers to Startup Development in Japan

These are the 7 biggest obstacles to Japanese startup success.

1. Unresponsive Employment Market

While the lifelong employment system in Japan is evolving, the average employee stays at their firm for 12 years (15 years for men at large organizations) compared to 4.3 years in the US. Seniority, not experience or aptitude, determines career routes, making it tough to quit a job to join a startup and then return to corporate work if it fails.

1. Conservative Buyers

Even if your product is buggy and undocumented, US customers will migrate to a cheaper, superior one. Japanese corporations demand perfection from their trusted suppliers and keep with them forever. Startups need income fast, yet product evaluation takes forever.

1. Failure intolerance

Japanese business failures harm lives. Failed forever. It hinders risk-taking. Silicon Valley embraces failure. Build another startup if your first fails. Build a third if that fails. Every setback is viewed as a learning opportunity for success.

4. No Corporate Purchases

Silicon Valley industrial giants will buy fast-growing startups for a lot of money. Many huge firms have stopped developing new goods and instead buy startups after the product is validated.

Japanese companies prefer in-house product development over startup acquisitions. No acquisitions mean no startup investment and no investor reward.

Startup investments can also be monetized through stock market listings. Public stock listings in Japan are risky because the Nikkei was stagnant for 35 years while the S&P rose 14x.

5. Social Unity Above Wealth

In Silicon Valley, everyone wants to be rich. That creates a competitive environment where everyone wants to succeed, but it also promotes fraud and societal problems.

Japan values communal harmony above individual success. Wealthy folks and overachievers are avoided. In Japan, renegades are nearly impossible.

6. Rote Learning Education System

Japanese high school graduates outperform most Americans. Nonetheless, Japanese education is known for its rote memorization. The American system, which fails too many kids, emphasizes creativity to create new products.

1. Immigration.

Immigrants start 55% of successful Silicon Valley firms. Some come for university, some to escape poverty and war, and some are recruited by Silicon Valley startups and stay to start their own.

Japan is difficult for immigrants to start a business due to language barriers, visa restrictions, and social isolation.

How Japan Can Promote Innovation

Patchwork solutions to deep-rooted cultural issues will not work. If customers don't buy things, immigration visas won't aid startups. Startups must have a chance of being acquired for a huge sum to attract investors. If risky startups fail, employees won't join.

Will Japan never have a startup culture?

Once a consensus is reached, Japan changes rapidly. A dwindling population and standard of living may lead to such consensus.

Toyota and Sony were firms with renowned founders who used technology to transform the world. Repeatable.

Silicon Valley is flawed too. Many people struggle due to wealth disparities, job churn and layoffs, and the tremendous ups and downs of the economy caused by stock market fluctuations.

The founders of the 10% successful startups are heroes. The 90% that fail and return to good-paying jobs with benefits are never mentioned.

Silicon Valley startup culture and Japanese corporate culture are opposites. Each have pros and cons. Big Japanese corporations make the most reliable, dependable, high-quality products yet move too slowly. That's good for creating cars, not social networking apps.

Can innovation and success be encouraged without eroding social cohesion? That can motivate software firms to move fast and break things while recognizing the beauty and precision of expert craftsmen? A hybrid culture where Japan can make the world's best and most original items. Hopefully.

It's kids' digital crack

TikTok is a destructive social media platform.

• The interface shortens attention spans and dopamine receptors.

• TikTok shares more data than other apps.

• Seeing an endless stream of dancing teens on my glowing box makes me feel like a Blade Runner extra.

TikTok did in one year what MTV, Hollywood, and Warner Music tried to do in 20 years. TikTok has psychotized the two-thirds of society Aldous Huxley said were hypnotizable.

Millions of people, mostly kids, are addicted to learning a new dance, lip-sync, or prank, and those who best dramatize this collective improvisation get likes, comments, and shares.

TikTok is a great app. So what?

The Commercial Magnifying Glass TikTok made me realize my generation's time was up and the teenage Zoomers were the target.

I told my 14-year-old sister, "Enjoy your time under the commercial magnifying glass."

TikTok sells your every move, gesture, and thought. Data is the new oil. If you tell someone, they'll say, "Yeah, they collect data, but who cares? I have nothing to hide."

It's a George Orwell novel's beginning. Look up Big Brother Award winners to see if TikTok won.

TikTok shares your data more than any other social media app, and where it goes is unclear. TikTok uses third-party trackers to monitor your activity after you leave the app.

Consumers can't see what data is shared or how it will be used. — Genius URL

32.5 percent of Tiktok's users are 10 to 19 and 29.5% are 20 to 29.

TikTok is the greatest digital marketing opportunity in history, and they'll use it to sell you things, track you, and control your thoughts. Any of its users will tell you, "I don't care, I just want to be famous."

TikTok manufactures mental illness

TikTok's effect on dopamine and the brain is absurd. Dopamine controls the brain's pleasure and reward centers. It's like a switch that tells your brain "this feels good, repeat."

Dr. Julie Albright, a digital culture and communication sociologist, said TikTok users are "carried away by dopamine." It's hypnotic, you'll keep watching."

TikTok constantly releases dopamine. A guy on TikTok recently said he didn't like books because they were slow and boring.

The US didn't ban Tiktok.

Biden and Trump agree on bad things. Both agree that TikTok threatens national security and children's mental health.

The Chinese Communist Party owns and operates TikTok, but that's not its only problem.

• There’s borderline child porn on TikTok

• It's unsafe for children and violated COPPA.

• It's also Chinese spyware. I'm not a Trump supporter, but I was glad he wanted TikTok regulated and disappointed when he failed.

Full-on internet censorship is rare outside of China, so banning it may be excessive. US should regulate TikTok more.

We must reject a low-quality present for a high-quality future.

TikTok vs YouTube

People got mad when I wrote about YouTube's death.

They didn't like when I said TikTok was YouTube's first real challenger.

Indeed. TikTok is the fastest-growing social network. In three years, the Chinese social media app TikTok has gained over 1 billion active users. In the first quarter of 2020, it had the most downloads of any app in a single quarter.

TikTok is the perfect social media app in many ways. It's brief and direct.

Can you believe they had a YouTube vs TikTok boxing match? We are doomed as a species.

YouTube hosts my favorite videos. That’s why I use it. That’s why you use it. New users expect more. They want something quicker, more addictive.

TikTok's impact on other social media platforms frustrates me. YouTube copied TikTok to compete.

It's all about short, addictive content.

I'll admit I'm probably wrong about TikTok. My friend says his feed is full of videos about food, cute animals, book recommendations, and hot lesbians.

Whatever.

TikTok makes us bad

TikTok is the opposite of what the Ancient Greeks believed about wisdom.

It encourages people to be fake. It's like a never-ending costume party where everyone competes.

It does not mean that Gen Z is doomed.

They could be the saviors of the world for all I know.

TikTok feels like a step towards Mike Judge's "Idiocracy," where the average person is a pleasure-seeking moron.

In the early 2000s, I began developing SaaS. I helped launch an internet fax service that delivered faxes to email inboxes. Back then, it saved consumers money and made the procedure easier.

Google AdWords was young then. Anyone might establish a new website, spend a few hundred dollars on keywords, and see dozens of new paying clients every day. That's how we launched our new SaaS, and these clients stayed for years. Our early ROI was sky-high.

Changing times

The situation changed dramatically after 15 years. Our paid advertising cost $200-$300 for every new customer. Paid advertising takes three to four years to repay.

Fortunately, we still had tens of thousands of loyal clients. Good organic rankings gave us new business. We needed less sponsored traffic to run a profitable SaaS firm.

Is it still possible?

Since selling our internet fax firm, I've dreamed about starting a SaaS company. One I could construct as a lone developer and progressively grow a dedicated customer base, as I did before in a small team.

It seemed impossible to me. Solo startups couldn't afford paid advertising. SEO was tough. Even the worst SaaS startup ideas attracted VC funding. How could I compete with startups that could hire great talent and didn't need to make money for years (or ever)?

The One and Only Way to Learn

After years of talking myself out of SaaS startup ideas, I decided to develop and launch one. I needed to know if a solitary developer may create a SaaS app in 2022.

Thus, I did. I invented webwriter.ai, an AI-powered writing tool for website content, from hero section headlines to blog posts, this year. I soft-launched an MVP in July.

Considering the Issue

Now that I've developed my own fully capable SaaS app for site builders and developers, I wonder if it's still possible. Can webwriter.ai be successful?

I know webwriter.ai's proposal is viable because Jasper.ai and Grammarly are also AI-powered writing tools. With competition comes validation.

To Win, Differentiate

To compete with well-funded established brands, distinguish to stand out to a portion of the market. So I can speak directly to a target user, unlike larger competition.

I created webwriter.ai to help web builders and designers produce web content rapidly. This may be enough differentiation for now.

Budget-Friendly Promotion

When paid search isn't an option, we get inventive. There are more tools than ever to promote a new website.

• Organic Results

• on social media (Twitter, Instagram, TikTok, LinkedIn)

• Marketing with content that is compelling

• Link Creation

• Listings in directories

• references made in blog articles and on other websites

• Forum entries

The Beginning of the Journey

As I've labored to construct my software, I've pondered a new mantra. Not sure where that originated from, but I like it. I'll live by it and teach my kids:

“Do the work.”

Here's the fastest way to validate company concepts.

I squandered a year after dropping out of Stanford designing a product nobody wanted.

But today, I’m at 100k!

Differences:

I was designing a consumer product when I dropped out.

I coded MVP, got 1k users, and got YC interview.

Nice, huh?

WRONG!

Still coding and getting users 12 months later

WOULD PEOPLE PAY FOR IT? was the riskiest assumption I hadn't tested.

When asked why I didn't verify payment, I said,

Not-ready products. Now, nobody cares. The website needs work. Include this. Increase usage…

I feared people would say no.

After 1 year of pushing it off, my team told me they were really worried about the Business Model. Then I asked my audience if they'd buy my product.

So?

No, overwhelmingly.

I felt like I wasted a year building a product no one would buy.

Founders Cafe was the opposite.

Before building anything, I requested payment.

40 founders were interviewed.

Then we emailed Stanford, YC, and other top founders, asking them to join our community.

BOOM! 10/12 paid!

Without building anything, in 1 day I validated my startup's riskiest assumption. NOT 1 year.

Asking people to pay is one of the scariest things.

I understand.

I asked Stanford queer women to pay before joining my gay sorority.

I was afraid I'd turn them off or no one would pay.

Gay women, like those founders, were in such excruciating pain that they were willing to pay me upfront to help.

You can ask for payment (before you build) to see if people have the burning pain. Then they'll pay!

Examples from Founders Cafe members:

😮 Using a fake landing page, a college dropout tested a product. Paying! He built it and made $3m!

😮 YC solo founder faked a Powerpoint demo. 5 Enterprise paid LOIs. $1.5m raised, built, and in YC!

😮 A Harvard founder can convert Figma to React. 1 day, 10 customers. Built a tool to automate Figma -> React after manually fulfilling requests. 1m+

Bad example:

😭 Stanford Dropout Spends 1 Year Building Product Without Payment Validation

Some people build for a year and then get paying customers.

What I'm sharing is my experience and what Founders Cafe members have told me about validating startup ideas.

Don't waste a year like I did.

After my first startup failed, I planned to re-enroll at Stanford/work at Facebook.

After people paid, I quit for good.

I've hit $100k!

Hope this inspires you to request upfront payment! It'll change your life