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[Music] Welcome, Halle. Thanks, guys. Good to be here. >> Good to be here.
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>> Great to have you with us.
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So, Halle, we're here to discuss your giant idea of massively improving health care. Yeah.
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>> Um let's start with the US.
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The US spends more on health care than I think any other high-income country. >> Correct.
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>> And scores very low on a number of factors: access, comorbidities, lifespan.
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What is the core systemic issue with the US health care system? Oh my gosh.
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I don't know if I could distill it to one core issue.
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Um maybe inefficiency, if I had to choose one word.
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Um but not just inefficiency in terms of the delivery of care, but the way that we've structured all the stakeholders within health care.
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And we've added so many layers of middlemen.
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And as you know, a lot of times middlemen create a lot of waste and a lot of inefficiency.
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And so, I would say that's a huge part of it.
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Um and then the incentive structure.
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So, we have a very reactive care system that incentivizes care versus any preventive measures.
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So, kind of those two things I would say are are the main reasons why we just haven't been able to achieve the same sort of outcomes that you would expect for paying as much as we pay per capita.
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Can you break that down just a little bit more for some of our listeners?
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Some will never have had the pleasure of receiving that letter in the mail from an insurance company in the US that says, "You owe $5,000."
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>> Um so, maybe just break down why how that happens for people and you know, what the incentive structures are. >> Yeah.
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Well, the first thing to know is that in the US most Americans are given insurance through their employers.
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So, more people are on employer-based care than anything else.
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That being said, we still have about 18% of people on Medicare and 18% of people on Medicaid.
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So, a good chunk are on a version of socialized medicine.
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>> Um but most of us are given health care by our our employers, and we don't have much say in what that health care looks like.
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We might have two or three options within that, but generally like the employer shapes that experience.
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And today, people are with their employers for can you guess how long? Not long. Two years, three years.
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Um so, when you think about investing in someone's health, you really need to see that ROI in a quite short time frame.
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We enroll in health care every single year.
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Um and then if you're at an employer for two or three years, investing in something that you won't see the ROI for 5 to 10 years doesn't really make sense.
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So, that we call the time horizon problem within health care.
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So, I guess the people receiving natural health care, I e.
2:30
, you know, the people living in America, there's not really um a strong incentive for the end deliverer of the health care, the insurance companies, to either optimize the delivery, optimize the cost, or optimize the quality of the care. Yeah.
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We say it's they're just passing the buck until someone goes on Medicare. Okay.
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Which is the public plan.
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Can we just just just drill onto that a little bit?
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It is sort of people might be confused why the insurance companies would not want to force cost down, because ultimately they've got to pay for a lot of it.
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Why do the insurance companies not go and force cost down? Great question.
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So, um one of the big pieces of legislation that changed health care in the US was Obamacare or the Affordable Care Act.
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And in a lot of ways, it moved health care forward.
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And one of the things it did was it um it didn't allow health plans to deny someone for pre-existing conditions.
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So, we saw an increase in the number of insured people and a decrease in people who are uninsured. So, that was great.
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But another thing it did was it capped the profits of insurers to 15%.
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And we call that the medical loss ratio. Okay.
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And so, you'd think that was a good thing.
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And I think overall, that is a good thing.
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But can you guess what happens when you cap profits to 15%?
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How can insurance companies make money?
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Just >> There's one way to make money that >> Increase prices. Yeah. Yeah.
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They have to grow the pie.
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And so, that's really what we saw happen is that they actually benefit from prices and premiums going up because their profit is capped. Okay. Let slight digression.
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Let's let's talk about the people in the US who are worst off in this system.
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So, we talked about Obamacare. Yeah.
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I was on the 2008 campaign.
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And the thing that gave me the most pride from that was was a very significant proportion of people who didn't have any insurance suddenly got some insurance. >> Yeah. And it gets 30 million.
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>> like 30 or 40 million even. Yeah, I think 40.
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How how many people now in the US just don't have any insurance?
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Because that's gone backwards, hasn't it? >> Yeah.
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Um I think it's still pretty low.
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Obviously right now, uh we're facing a lot of Medicaid cuts. >> Sure.
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And so, with that I think we'll probably see an increase in the uninsured.
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Um but it's still quite low.
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It's been it's been quite effective. >> Okay.
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But that's people who have no insurance.
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There's a number of people who have insurance but incredibly high deductibles, so do pay for most of their health care out of pocket. >> Absolutely, yes.
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Um so, the rate of people who can't afford health care is much greater than the rate of people who are uninsured. >> Okay. For exactly that reason.
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And we're starting to see folks who actually are choosing these high deductible plans and just kind of avoiding care and using health insurance more as a catastrophic plan. Right.
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So, it's the cheapest on a monthly basis.
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And when I say cheap, it's still not cheap, right?
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It's hundreds of dollars a month.
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Um but they're saying, "I'm just going to avoid any any care beyond there are preventive services that are required by the ACA.
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So, you are you have certain things that will be 100% covered by your health plan.
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So, people will do that and then they will basically stay out of the health care system.
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They will avoid having to take medication and use the insurance as kind of this backup plan, because they can't afford anything else.
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They can't afford what they call the Cadillac plans.
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And this is not good, right?
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I mean, you've got a whole bunch of people who should be accessing health care who are just simply not doing it. Correct.
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And so, what we're seeing now is a rise of companies in the longevity space that are attracting uh a certain demographic of higher-income folks who are not being well served by the health care system, who are willing to pay out of pocket.
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And they're starting to say, "Well, actually the sort of health care that I want is very different from what's offered right now.
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And my health plan is never going to cover a thousand biomarker test or a a non-indicated full-body MRI scan, uh but I want to take health care into my own hands."
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And so, it's exciting to see because as we know, these early adopters, while they're willing to pay high prices, hopefully that group of individuals grows as the price goes down and we kind of normalize proactive care and make it accessible to more people.
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So, we've diagnosed the problem probably at its core it's about perverse incentives, right? >> Yes.
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>> And not having good alignment of incentives between the insurers, the companies, and and and the consumers of the health care.
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If you were to reorganize US health care today, if you had a blank page, what is the single kind of organizing principle you would use?
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>> So, one of the things that I um am a proponent of is portable insurance.
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So, you can sign up instead of signing up in one-year increments, you can sign up on 10-year increments.
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And if you can imagine a health plan that is going to be with you for 10 years, they have different sort of incentives.
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So, I think that is one principle that I would continue seeing.
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I'm also I'm a capitalist.
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And I also think that competition amongst providers is really important.
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And so, I think I would do more to even encourage competition, because we know that in areas with fewer providers, the prices are actually higher. They're not competing.
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And so, when you look at services um in places like New York City, sometimes it's actually less expensive even though general cost of living is higher because they have more competition.
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So, I'm all about competition there.
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I'm also about competition in health plans.
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Like, why can't your your employer give you a set amount of money and you go shop for that health plan?
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So, then all of a sudden health plans are competing for your business versus competing for Janet in HR's business, who's choosing on behalf of thousands employees.
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So, consumer choice, competition, these are things that I think are really important.
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>> On on consumer choice and competition, I remember a few years ago being pitched a startup, two brilliant US health care founders who as founders I would back for sure.
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They're obviously brilliant, you know, founders.
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>> Well, because their idea was to provide transparency on health care pricing in New York.
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So, their idea was to basically make it, you know, on a website very publicly transparent what the different prices were in different hospitals for various medications and health care procedures.
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And when we did the kind of network diligence on it and spoke to experts, they just said very clearly, "There is no way the incumbents are going to allow this to happen.
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They are not going to allow price transparency to get out there.
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They will crush these guys."
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And I said, "Well, how are they going to do it?
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You know, this is America.
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It's the land of competition." That is so scary.
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And they just said they will crush them with uh with with nuisance lawsuits.
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They'll go after them through regulatory channels.
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Um give give us a sense and our listeners a sense of the the sort of the death knell of competition because of these incumbents who are so powerful, so well organized, so well funded.
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And you've you've spent your career in some ways trying to break down that system. Yeah.
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Tell us how they how they play dirty, how they stop stop this stuff happening.
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Well, hospitals today are actually required to publish their charge masters.
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So, they are required to provide um transparency around the cash pay prices.
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Most people don't pay cash pay.
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Uh cash pay is generally higher, right?
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To go into a hospital and pay on your own.
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You're a single person negotiating.
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A health plan can go and negotiate lower rates.
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So, any health plan option is going to be lower.
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However, we now have more data than we've ever had before on the price of procedures.
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And founders are starting to use this to to give consumers more choice and say.
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Um I think actually I'm on the board of a company called Collective Health.
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And we actually do this in within the employer realm, because we know that employers are the ones that are delivering most of the health plans.
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Uh so, we allow employees to select based on price and quality uh within the network that they're able to go to.
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So, that's kind of the in in that place kind of the right workflow in my mind.
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For a direct-to-consumer option, you'd be limited to those cash pay patients who are probably less tech-savvy. Okay.
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So, that's some of the solutions.
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But you I mean, just just to push on, is my characterization of the incumbents unfair or or are they very resistant to change and well organized in preventing it?
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>> Yeah, I mean, I talk about this a lot in my book, but we an issue with the incumbent blockade, as I call it.
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And there's a lot of regulatory capture in the US.
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And the incumbents have a tremendous amount of power and not just within the market, but they have they've they've bent regulatory in their favor. >> they do that?
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>> Yeah, maybe maybe a bit of history. How did that happen?
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I mean lot Do we have We have lobbyists in the UK the way we have in the US?
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Yeah, I mean healthcare lobbyists are the the biggest lobbyists in DC. Okay.
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They have a tremendous amount of influence.
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There are a lot of like little examples of it within pharma, within health plans, even providers have people on the ground in DC that are shaping policy in their favor. Here's one example.
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So, there's something called CON laws.
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And these are actually at a state level, not federal level, that require any new provider delivering care to give to get approval of other providers in that area before they can open up new brick-and-mortar practices.
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So, you can imagine getting your competitors to sign off on you opening up a new clinic in a certain area.
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They have to determine say actually there is a need or there's not a need.
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And those are your competitors that are determining that.
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So, you know, that's not really fair.
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That's not really pro-competition and pro-capitalist.
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That's that they can kind of stop and block their competitors in that way.
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>> just to give people a sense of the scale of this industry and these companies, UHC is worth 100 billion, 200 billion dollars Oh, yeah.
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I mean these If you look at even just like the top 20 biggest companies, most of them are are healthcare.
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And they're names that you might not even know if you're not a healthcare person like McKesson and Cardinal.
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A lot of these Yeah, United Healthcare.
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I mean hopefully people know United Healthcare because they're they're so well known now.
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But yeah, a lot of these companies are just massive and they they want to keep their their protective in the market.
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Yeah, they absolutely do.
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And they're And they're, you know, in many ways hated entities now.
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I mean most famously recently the kind of horrific murder of the United Healthcare CEO, I think, and and the sort of surprising actually support for that, right?
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Amongst not just people you would you would view as extremist.
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Treating treating a murderer as an idol for a lot of folks, I think is is is terrible, but it's also symbolic of where we are.
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And there is absolutely a consumer uprising that I'm seeing that's really bubbling up and that is an extreme example.
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But we also saw So, I think it was Blue Cross, one of the Blues plans, actually stated that they're going to put a cap on the amount of anesthesia they would pay for a patient.
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And you don't know how long you're going to be under beforehand, but they were going to cap it.
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And if you went over, you'd have to pay for it.
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And they did this I think last October and people were outraged.
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Actually, this is like a month or two before Brian Thompson was killed.
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And people were so upset and even like the anesthesiologists were really upset about this because why capping anesthesia?
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Like trust the anesthesiologist not to keep someone on for too long.
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Like why would they try to control that?
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And actually they reversed their decision about a month later because of that uprising. Wow.
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So, people are starting to pay attention.
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The other thing that's happening that's new is that a lot of employees are starting to sue their employers for mismanaging the funds.
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Because technically, if you think about your health plan that's paid for by your employer think it's paid for by your employer, you're actually paying for that, right?
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You're exchange You would have had higher wages had you not had to put so much into that health plan.
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And so now a lot of employees are starting to say, "Wait a minute. You You chose this plan.
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You chose to work with this PBM, but this PBM actually we think is overcharging us."
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And so we're starting to see like a level of sophistication from patients and consumers that are starting to hold their employers accountable.
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And to me that's very exciting.
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So, it sounds like any entrepreneur trying to reinvent the healthcare system in the US has some serious mountains to climb. Yes.
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But you know, how would those that have succeeded, those that are kind of changing the game, what what are they doing?
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How are they how are they navigating this quagmire of incumbents and status quo oligopolists and all the rest of it? Yeah.
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I think timing is a big piece of it.
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I've been in this industry long enough that ideas that didn't work 10 years ago are like the timing is right.
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And so I think sometimes it's just really paying attention to what the market is ready for versus what's a good idea.
14:14
Can you give us a few examples?
14:17
Yeah, well, I mean I think all of these biomarker companies that we're seeing like Function Health that, you know, there was one called Wellness FX that I did in San Francisco probably 15 years ago now and I I thought it was really cool.
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They sent a phlebotomist to your home, they took your blood work, they followed up with anything that was irregular and you got to be on a plan to do that every 6 months that you could kind of proactively manage your healthcare.
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That didn't That company didn't work out.
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You don't know about it now, but now there are dozens of companies that are offering really seamless, you know, at home or in a you know, at your local clinic to get a quick blood test that can give you so much data about yourself.
14:52
So, I think that there's now a lot more appetite from consumers that are willing to pay now that weren't willing to pay willing and able to pay now. So, that's a one area.
15:05
But in terms of how they're those that are succeeding are doing and I think So, part of it is timing and knowing like what the market is ready for and understanding where you can break the system without breaking yourself where you can kind of move actually move things and and make a difference.
15:19
And then I think another is just like really smart business models because a lot of folks come to healthcare and don't realize how much of the mission that's going to matter in terms of your outcomes.
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There are a lot of ways to make money in healthcare where the mission and the margin are not aligned.
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So, you end up making more money by not actually fulfilling the mission of patient health and longevity or whatever that mission is.
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And so I think founders who get really smart about their business model and think about how they can align those two things are going to be in a much better position to make a difference and create an enduring company.
15:52
What I've seen too from our investments at Giant is kind of two types One that's actually trying to build something outside the system from the ground up like companies like Sesame, which is a the direct you know, a cash pay marketplace for people who want to you know, find healthcare outside of the insurance system.
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And that kind of supply and demand effect is actually really lowering the cost of healthcare on the marketplace in Sesame, which is pretty good to see.
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Another one we backed called RX Diet is a food as medicine company helping deliver affordable and nutritious food to members on insurance plans.
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And the insurance companies are actually paying them to do that.
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There's both models like you can build outside of it or you know, you can kind of work within it to improving that that can also be very powerful in delivering better health outcomes and building very high growth companies.
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And we see a lot of companies go from one direction to the other.
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So, they might start cash pay and then start adding on >> Yeah.
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insurance cuz it takes a long time to go state by state and plan by plan in becoming in network.
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But then we also see the other way around of people who start selling to employers or health plans and then they're like, "Actually, let's turn on a direct-to-consumer model."
16:55
But the through line is more money still keeps getting spent on healthcare. Yes. Yeah, no.
17:00
More money and and not necessarily better outcomes.
17:02
So, I mean the thing that I was reflecting on the way on the way to this interview was that our day job is makes you an optimist, right?
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We're constantly meeting, as you are, amazing founders who are using technology to go solve healthcare problems.
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And, you know, it makes you very optimistic.
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People are doing amazing stuff.
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We back companies using molecular glues to drug undruggable proteins.
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And obviously the explosion of AI for drug discovery.
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And so we have this intelligence.
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We're almost at super intelligence level as as a as a society as a human race.
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And you would think therefore things are going to get a lot better.
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But if you actually kind of step back, life expectancy has plateaued over the last 10 to 15 years.
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It obviously went down with COVID.
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And And we look at it, why?
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COVID, but also opioids, you know, clearly obesity is a big one.
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And so you kind of you look at the optimism that we have the kind of techno-optimism around medicine and and AI and how it's going to solve these things.
17:53
But ultimately you know, I guess if you step back, the food we're eating, the society we live in, the stress levels, the way we're living as human beings has to also clearly improve.
18:02
There doesn't seem to be much focus on that, I would say.
18:04
What What's your take on that? Yeah, I agree.
18:06
I mean I don't think we we categorize that as healthcare, unfortunately.
18:09
I have a degree in public health.
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So, in my mind I do think of the what we call the social determinants of health, which is your everyday environment.
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It's are you walking to work or are you sitting in a car for 45 minutes?
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Are you sitting in traffic?
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Is that adding stress to your life?
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Does that mean you're getting home late and you're eating like a granola bar and cereal for dinner?
18:27
And so all of these things, as you said, like really do play in a part in our outcomes that are outside of what we consider healthcare.
18:39
And so I do think that it's really important that we think about kind of public health messaging even though public health is under fire right now, but how can innovators kind of take that public health lens to encourage and make it easier to live a healthy life because the end of the day we can in the US especially we have this idea that it's like individualism and your outcomes are because of your actions.
18:59
But when you live in the United States and you have to drive everywhere because we don't have good public transit in most cities and we have food deserts in a lot of areas and we don't have access and so many people are disenfranchised from the medical system, you have to really wonder like is that an individual problem or is that a system problem?
19:17
And so these are things that like a lot of that's going to take a lot of things outside of the entrepreneurial ecosystem to solve, but I'm very bullish that we can work together with regulators, with public health officials to kind of move together in the right direction.
19:36
>> What do what do we collectively think?
19:37
Do we think that despite the public health issues and the obesity crisis and all that?
19:40
Do we think the power of AI is just going to going to blitz through that and through through medication and personalized medicine? Oh.
19:45
I mean Is it just going to override all these problems?
19:49
>> I Yes, I am so so bullish on AI in healthcare.
19:53
Um Like one area that I spent a lot of time thinking about is just chronic disease management.
20:00
And there are a lot of ways that So, the example I give is I have asthma, but I have two medications.
20:04
I have a preventive inhaler and I have a rescue inhaler. >> Right.
20:09
And if I don't take my preventive inhaler, then I could have an asthma attack.
20:12
But if I do take it, then I have some symptoms.
20:16
Like I'm a little bit jittery, I don't sleep well, and so I actually don't like to take it unless I know that I'm going to have a trigger.
20:21
So, certain seasons I'll be taking it if I know I'm going to be exposed to some of my allergy-induced asthma triggers, but I'm kind of like self-managing throughout the year.
20:31
And then I take the lung function test once a year, and depending on the time of year that is, if it's during like my allergy season, I do worse.
20:38
And if it's like in the winter, I'll do better.
20:41
But I'm really self-managing and I'm a pretty savvy consumer, so I can do that.
20:46
But imagine if I actually had a tool that connected my triggers and basic data of the environment and told me, "Today be a good day to take your inhaler.
20:56
Have you take taken your inhaler today?"
20:57
And then what if I also had a at-home spirometer that I could just blow into once a month, once a week, whatever it is, that I could know my lung function to know if I need to be taking my preventive inhaler.
21:08
Because if I have to get to the point of taking my rescue inhaler and go to the hospital, that's going to be a lot more money than an ambient tool that I'm like texting with every day that's checking in with me.
21:20
That's something my doctor could not possibly do.
21:21
So, I think there's a lot of areas like that with chronic disease management that we can finally get to personalized medicine.
21:27
And that's what When I think of personalized medicine, I think traditionally you think of like personalized treatment.
21:32
But in this way, it's also just managing the chronic illness on a day-to-day basis in a way that like ebbs and flows with your disease.
21:41
Because the fact is, no matter if you have diabetes or if you have asthma, it's not the same every day.
21:44
And your doctor gets just a small snapshot on the day that they see you for 15 minutes, mind you.
21:51
I I think I think AI will help both of the personalization.
21:53
I think that's definitely one big one.
21:54
I think it will also help automate so much so much more of healthcare operations, whether it's, you know, inside the hospital or outside the hospital, checking in, making sure that people are taking their medication.
22:04
But I still think that the core issue is a systems issue.
22:08
And even though the technology will help drive down the cost of delivery of care and improve the personalization of care, I think it won't do it as much as we think is my is my is my take, unfortunately.
22:16
Cuz I see it here in the NHS in the UK. Interesting.
22:21
Those technologies are there.
22:22
They even pre-date >> Well, they don't You don't have as much administrative burden here.
22:25
Uh >> Cuz you have a single-payer.
22:28
>> we have a different kind of administrative burden would be my take.
22:30
>> Well, let's talk about that, Addy, cuz you just moved to the UK. Yeah.
22:32
Like many successful US technologists, you A lot of us coming over here these days. >> yeah, I wonder why.
22:39
>> invasion is is happening. >> Yes.
22:41
Well, we won't ask you why you've come, but we will ask you, what do you think just from a first principles kind of view, in the US basically Yeah.
22:47
in most people, their employers pay for their healthcare, but really that means, as you said, they pay for it because it would have been their wages.
22:53
And here, the state pays.
22:56
Which again, you pay for it through your taxes. >> Yeah, correct.
23:00
From a first principles view, is one better than the other in in like if you designed it really well? >> Yeah.
23:05
So, I do think that single-payer has more efficiencies than having many many thousands of payers that providers have to contract with.
23:12
There's just an inefficiency there.
23:16
But what is nice about having many players is in theory, you have choice and competition.
23:21
But we have neither, right?
23:23
Like in a in a perfect system, you'd have you'd have many options and competition so that they would actually compete on price and quality.
23:29
So, I would say that I'd pick a single-payer over a multi-multi-payer system with no choice. Okay.
23:37
But what I think is neat here, and actually is the model in Japan, which I really like, is that you still have some competition amongst providers.
23:47
And I do think that that is important.
23:48
While you have the NHS, they are kind of their own provider groups.
23:52
And so, I do think it's important that we we continue to compete on price and quality.
23:56
But I guess you could push this maybe a lack of alignment incentives in the model here in the sense that while taxpayers do pay for their healthcare, it's not a very tight relationship.
24:05
So, there's kind of no disincentive to consume as much healthcare as possible. >> Sure. Sure.
24:10
A lot of people want the French model where to solve that, where you've got to pay at least something to make it a bit more real for you that you are not, you know, you're you're not consuming something.
24:18
Is that But there's obviously huge resistance to that.
24:21
No one is willing to touch it in the UK.
24:23
>> Well, I can't complain about it yet cuz I don't feel like it's not my right to complain about it yet, but let's do this episode again in 5 years as I learn more about it and complain.
24:31
But I will say this, for a year of NHS for me to get covered is a thousand dollars or thousand pounds, rather. So, what would that be?
24:40
$1,400 for a year of care.
24:43
In the US, I pay more than that per month. Yeah, wow.
24:47
I remember hearing one line that stuck with me though, that the US and if you look at the US budget and the UK budget, the US has a has a defense line item and the UK has a healthcare line item, which is the NHS, and that's the majority of it.
25:00
If we take a step back and your giant idea of massively better healthcare gets rolled out across the US and maybe even globally, what does that really look like for patients?
25:08
What's what's the positive world we could paint 10 10 20 years down the road?
25:13
Yeah, I mean, it's it's innovators that have the opportunity to build companies that are drastically changing what healthcare looks like.
25:18
So, my book isn't laying out the direction, it's supporting people who have the ideas to change healthcare for the better, whether that is lowering costs, whether that's improving outcomes through more personalized medicine, or just increasing access and giving people options that they never had before. Amazing. Amazing.
25:36
Addy, thanks so much for sharing your giant idea. We really appreciate it. [Music]