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.

Looking back into the past can help you understand what's happening today and why.

"Creator economy" conjures up images of originality, sincerity, and passion. Where do Michelangelos and da Vincis push advancement with their gifts without battling for bread and proving themselves posthumously? 

Creativity has been as long as humanity, but it's just recently become a new economic paradigm. We even talk about Web3 now.

Let's examine the creative economy's history to better comprehend it. What brought us here? Looking back can help you understand what's happening now.

No yawning, I promise 😉.

Creator Economy's history

Long, uneven transition to creator economy. Let's examine the economic and societal changes that led us there.

1. Agriculture to industry

Mid-18th-century Industrial Revolution led to shift from agriculture to manufacturing. The industrial economy lasted until World War II.

The industrial economy's principal goal was to provide more affordable, accessible commodities.

Unlike today, products were scarce and inaccessible.

To fulfill its goals, industrialization triggered enormous economic changes, moving power from agrarians to manufacturers. Industrialization brought hard work, rivalry, and new ideas connected to production and automation. Creative thinkers focused on that then.

It doesn't mean music, poetry, or painting had no place back then. They weren't top priority. Artists were independent. The creative field wasn't considered a different economic subdivision.

2. The consumer economy

Manufacturers produced more things than consumers desired after World War II. Stuff was no longer scarce.

The economy must make customers want to buy what the market offers.

The consumer economic paradigm supplanted the industrial one. Customers (or consumers) replaced producers as the new economic center.

Salesmen, marketing, and journalists also played key roles (TV, radio, newspapers, etc.). Mass media greatly boosted demand for goods, defined trends, and changed views regarding nearly everything.

Mass media also gave rise to pop culture, which focuses on mass-market creative products. Design, printing, publishing, multi-media, audio-visual, cinematographic productions, etc. supported pop culture.

The consumer paradigm generated creative occupations and activities, unlike the industrial economy. Creativity was limited by the need for wide appeal.

Most creators were corporate employees.

Creating a following and making a living from it were difficult.

Paul Saffo said that only journalists and TV workers were known. Creators who wished to be known relied on producers, publishers, and other gatekeepers. To win their favor was crucial. Luck was the best tactic.

3. The creative economy

Consumer economy was digitized in the 1990s. IT solutions transformed several economic segments. This new digital economy demanded innovative, digital creativity.

Later, states declared innovation a "valuable asset that creates money and jobs." They also introduced the "creative industries" and the "creative economy" (not creator!) and tasked themselves with supporting them. Australia and the UK were early adopters.

Individual skill, innovation, and intellectual property fueled the creative economy. Its span covered design, writing, audio, video material, etc. The creative economy required IT-powered activity.

The new challenge was to introduce innovations to most economic segments and meet demand for digital products and services.

Despite what the title "creative economy" may imply, it was primarily oriented at meeting consumer needs. It didn't provide inventors any new options to become entrepreneurs. Instead of encouraging innovators to flourish on their own, the creative economy emphasized "employment-based creativity."

4. The creator economy

Next, huge IT platforms like Google, Facebook, YouTube, and others competed with traditional mainstream media.

During the 2008 global financial crisis, these mediums surpassed traditional media. People relied on them for information, knowledge, and networking. That was a digital media revolution. The creator economy started there.

The new economic paradigm aimed to engage and convert clients. The creator economy allowed customers to engage, interact, and provide value, unlike the consumer economy. It gave them instruments to promote themselves as "products" and make money.

Writers, singers, painters, and other creators have a great way to reach fans. Instead of appeasing old-fashioned gatekeepers (producers, casting managers, publishers, etc.), they can use the platforms to express their talent and gain admirers. Barriers fell.

It's not only for pros. Everyone with a laptop and internet can now create.

2022 creator economy:

Since there is no academic description for the current creator economy, we can freestyle.

The current (or Web2) creator economy is fueled by interactive digital platforms, marketplaces, and tools that allow users to access, produce, and monetize content.

No entry hurdles or casting in the creative economy. Sign up and follow platforms' rules. Trick: A platform's algorithm aggregates your data and tracks you. This is the payment for participation.

The platforms offer content creation, design, and ad distribution options. This is platforms' main revenue source.

The creator economy opens many avenues for creators to monetize their work. Artists can now earn money through advertising, tipping, brand sponsorship, affiliate links, streaming, and other digital marketing activities.

Even if your content isn't digital, you can utilize platforms to promote it, interact and convert your audience, and more. No limits. However, some of your income always goes to a platform (well, a huge one).

The creator economy aims to empower online entrepreneurship by offering digital marketing tools and reducing impediments.

Barriers remain. They are just different. Next articles will examine these.

Why update the creator economy for Web3?

I could address this question by listing the present creator economy's difficulties that led us to contemplate a Web3 upgrade.

I don't think these difficulties are the main cause. The mentality shift made us see these challenges and understand there was a better reality without them.

Crypto drove this thinking shift. It promoted disintermediation, independence from third-party service providers, 100% data ownership, and self-sovereignty. Crypto has changed the way we view everyday things.

Crypto's disruptive mission has migrated to other economic segments. It's now called Web3. Web3's creator economy is unique.

Here's the essence of the Web3 economy:

• Eliminating middlemen between creators and fans.

• 100% of creators' data, brand, and effort.

• Business and money-making transparency.

• Authentic originality above ad-driven content.

In the next several articles, I'll explain. We'll also discuss the creator economy and Web3's remedies.

Final thoughts

The creator economy is the organic developmental stage we've reached after all these social and economic transformations.

The Web3 paradigm of the creator economy intends to allow creators to construct their own independent "open economy" and directly monetize it without a third party.

If this approach succeeds, we may enter a new era of wealth creation where producers aren't only the products. New economies will emerge.

This article is a summary. To read the full post, click here.

I apologize if this sounds basic, but throughout my career, I've always been clear that a company's activities are shaped by its founder(s)' morality.

I consider Palantir, owned by PayPal founder Peter Thiel, evil. He got $5 billion tax-free by hacking a statute to help middle-class savings. That may appear clever, but I think it demonstrates a shocking lack of solidarity with society. As a result of this and other things he has said and done, I early on dismissed Peter Thiel as someone who could contribute anything positive to society, and events soon proved me right: we are talking about someone who clearly considers himself above everyone else and who does not hesitate to set up a company, Palantir, to exploit the data of the little people and sell it to the highest bidder, whoever that is and whatever the consequences.

The German courts have confirmed my warnings concerning Palantir. The problem is that politicians love its surveillance tools because they think knowing more about their constituents gives them power. These are ideal for dictatorships who want to snoop on their populace. Hence, Silicon Valley's triumphalist dialectic has seduced many governments at many levels and collected massive volumes of data to hold forever.

Dangerous company. There are many more. My analysis of the moral principles that disclose company management changed my opinion of Facebook, now Meta, and anyone with a modicum of interest might deduce when that happened, a discovery that leaves you dumbfounded. TikTok was easy because its lack of morality was revealed early when I saw the videos it encouraged minors to post and the repercussions of sharing them through its content recommendation algorithm. When you see something like this, nothing can convince you that the firm can change its morals and become good. Nothing. You know the company is awful and will fail. Speak it, announce it, and change it. It's like a fingerprint—unchangeable.

Some of you who read me frequently make its Facebook today jokes when I write about these firms, and that's fine: they're my moral standards, those of an elderly professor with thirty-five years of experience studying corporations and discussing their cases in class, but you don't have to share them. Since I'm writing this and don't have to submit to any editorial review, that's what it is: when you continuously read a person, you have to assume that they have moral standards and that sometimes you'll agree with them and sometimes you won't. Morality accepts hierarchies, nuances, and even obsessions. I know not everyone shares my opinions, but at least I can voice them. One day, one of those firms may sue me (as record companies did some years ago).

Palantir is incredibly harmful. Limit its operations. Like Meta and TikTok, its business strategy is shaped by its founders' immorality. Such a procedure can never be beneficial.

Monkey jpegs and shitcoins have tarnished Web3's reputation. Let’s move on.

Web3 was called "the internet's future."

Well, 'crypto bros' shouted about it loudly.

As quickly as it arrived to be the next internet, it appears to be dead. It's had scandals, turbulence, and crashes galore:

• Web 3.0's cryptocurrencies have crashed. Bitcoin's all-time high was $66,935. This month, Ethereum fell from $2130 to $1117. Six months ago, the cryptocurrency market peaked at $3 trillion. Worst is likely ahead.

• Gas fees make even the simplest Web3 blockchain transactions unsustainable.

• Terra, Luna, and other dollar pegs collapsed, hurting crypto markets. Celsius, a crypto lender backed by VCs and Canada's second-largest pension fund, and Binance, a crypto marketplace, have withheld money and coins. They're near collapse.

• NFT sales are falling rapidly and losing public interest.

Web3 has few real-world uses, like most crypto/blockchain technologies. Web3's image has been tarnished by monkey profile pictures and shitcoins while failing to become decentralized (the whole concept is controlled by VCs).

The damage seems irreparable, leaving Web3 in the gutter.

Step forward our new saviour — Web5

Fear not though, as hero awaits to drag us out of the Web3 hellscape. Jack Dorsey revealed his plan to save the internet quickly.

Dorsey has long criticized Web3, believing that VC capital and silicon valley insiders have created a centralized platform. In a tweet that upset believers and VCs (he was promptly blocked by Marc Andreessen), Dorsey argued, "You don't own "Web3." VCs and LPs do. Their incentives prevent it. It's a centralized organization with a new name.

Dorsey announced Web5 on June 10 in a very Elon-like manner. Block's TBD unit will work on the project (formerly Square).

Web5's pitch is that users will control their own data and identity. Bitcoin-based. Sound familiar? The presentation pack's official definition emphasizes decentralization. Web5 is a decentralized web platform that enables developers to write decentralized web apps using decentralized identifiers, verifiable credentials, and decentralized web nodes, returning ownership and control over identity and data to individuals.

Web5 would be permission-less, open, and token-less. What that means for Earth is anyone's guess. Identity. Ownership. Blockchains. Bitcoin. Different.

Web4 appears to have been skipped, forever destined to wish it could have shown the world what it could have been. (It was probably crap.) As this iteration combines Web2 and Web3, simple math and common sense add up to 5. Or something.

Dorsey and his team have had this idea simmering for a while. Daniel Buchner, a member of Block's Decentralized Identity team, said, "We're finishing up Web5's technical components."

Web5 could be the project that decentralizes the internet. It must be useful to users and convince everyone to drop the countless Web3 projects, products, services, coins, blockchains, and websites being developed as I write this.

Web5 may be too late for Dorsey and the incoming flood of creators.

Web6 is planned!

The next months and years will be hectic and less stable than the transition from Web 1.0 to Web 2.0. 

• Web1 was around 1991-2004.

• Web2 ran from 2004 to 2021. (though the Web3 term was first used in 2014, it only really gained traction years later.)

• Web3 lasted a year.

• Web4 is dead.

Silicon Valley billionaires are turning it into a startup-style race, each disrupting the next iteration until they crack it. Or destroy it completely.

Web5 won't last either.

Are MVPs outdated and have no place in modern product culture?

Frank Robinson coined "MVP" in 2001. In the same year as the Agile Manifesto, the first Scrum experiment began. MVPs are old.

The concept was created to solve the waterfall problem at the time.

The market was still sour from the .com bubble. The tech industry needed a new approach. Product and Agile gained popularity because they weren't waterfall.

More than 20 years later, waterfall is dead as dead can be, but we are still talking about MVPs. Does that make sense?

What is an MVP?

Minimum viable product. You probably know that, so I'll be brief:

[…] The MVP fits your company and customer. It's big enough to cause adoption, satisfaction, and sales, but not bloated and risky. It's the product with the highest ROI/risk. […] — Frank Robinson, SyncDev

MVP is a complete product. It's not a prototype. It's your product's first iteration, which you'll improve. It must drive sales and be user-friendly.

At the MVP stage, you should know your product's core value, audience, and price. We are way deep into early adoption territory.

What about all the things that come before?

Modern product discovery

Eric Ries popularized the term with The Lean Startup in 2011. (Ries would work with the concept since 2008, but wide adoption came after the book was released).

Ries' definition of MVP was similar to Robinson's: "Test the market" before releasing anything. Ries never mentioned money, unlike Jobs. His MVP's goal was learning.

“Remove any feature, process, or effort that doesn't directly contribute to learning” — Eric Ries, The Lean Startup

Product has since become more about "what" to build than building it. What started as a learning tool is now a discovery discipline: fake doors, prototyping, lean inception, value proposition canvas, continuous interview, opportunity tree... These are cheap, effective learning tools.

Over time, companies realized that "maximum ROI divided by risk" started with discovery, not the MVP. MVPs are still considered discovery tools. What is the problem with that?

Time to Market vs Product Market Fit

Waterfall's Time to Market is its biggest flaw. Since projects are sliced horizontally rather than vertically, when there is nothing else to be done, it’s not because the product is ready, it’s because no one cares to buy it anymore.

MVPs were originally conceived as a way to cut corners and speed Time to Market by delivering more customer requests after they paid.

Original product development was waterfall-like.

Time to Market defines an optimal, specific window in which value should be delivered. It's impossible to predict how long or how often this window will be open.

Product Market Fit makes this window a "state." You don’t achieve Product Market Fit, you have it… and you may lose it.

Take, for example, Snapchat. They had a great time to market, but lost product-market fit later. They regained product-market fit in 2018 and have grown since.

An MVP couldn't handle this. What should Snapchat do? Launch Snapchat 2 and see what the market was expecting differently from the last time? MVPs are a snapshot in time that may be wrong in two weeks.

MVPs are mini-projects. Instead of spending a lot of time and money on waterfall, you spend less but are still unsure of the results.

MVPs aren't always wrong. When releasing your first product version, consider an MVP.

Minimum viable product became less of a thing on its own and more interchangeable with Alpha Release or V.1 release over time.

Modern discovery technics are more assertive and predictable than the MVP, but clarity comes only when you reach the market.

MVPs aren't the starting point, but they're the best way to validate your product concept.

Few sentences can have global significance.

Ethan Zuckerman invented the pop-up commercial in 1997.

He was working for Tripod.com, an online service that let people make little web pages for free. Tripod offered advertising to make money. Advertisers didn't enjoy seeing their advertising next to filthy content, like a user's anal sex website.

Zuckerman's boss wanted a solution. Wasn't there a way to move the ads away from user-generated content?

When you visited a Tripod page, a pop-up ad page appeared. So, the ad isn't officially tied to any user page. It'd float onscreen.

Here’s the thing, though: Zuckerman’s bit of Javascript, that created the popup ad? It was incredibly short — a single line of code:

window.open('http://tripod.com/navbar.html'
"width=200, height=400, toolbar=no, scrollbars=no, resizable=no, target=_top");

Javascript tells the browser to open a 200-by-400-pixel window on top of any other open web pages, without a scrollbar or toolbar.

Simple yet harmful! Soon, commercial websites mimicked Zuckerman's concept, infesting the Internet with pop-up advertising. In the early 2000s, a coder for a download site told me that most of their revenue came from porn pop-up ads.

Pop-up advertising are everywhere. You despise them. Hopefully, your browser blocks them.

Zuckerman wrote a single line of code that made the world worse.

I read Zuckerman's story in How 26 Lines of Code Changed the World. Torie Bosch compiled a humorous anthology of short writings about code that tipped the world.

Most of these samples are quite short. Pop-cultural preconceptions about coding say that important code is vast and expansive. Hollywood depicts programmers as blurs spouting out Niagaras of code. Google's success was formerly attributed to its 2 billion lines of code.

It's usually not true. Google's original breakthrough, the piece of code that propelled Google above its search-engine counterparts, was its PageRank algorithm, which determined a web page's value based on how many other pages connected to it and the quality of those connecting pages. People have written their own Python versions; it's only a few dozen lines.

Google's operations, like any large tech company's, comprise thousands of procedures. So their code base grows. The most impactful code can be brief.

The examples are fascinating and wide-ranging, so read the whole book (or give it to nerds as a present). Charlton McIlwain wrote a chapter on the police beat algorithm developed in the late 1960s to anticipate crime hotspots so law enforcement could dispatch more officers there. It created a racial feedback loop. Since poor Black neighborhoods were already overpoliced compared to white ones, the algorithm directed more policing there, resulting in more arrests, which convinced it to send more police; rinse and repeat.

Kelly Chudler's You Are Not Expected To Understand This depicts the police-beat algorithm.

Even shorter code changed the world: the tracking pixel.

Lily Hay Newman's chapter on monitoring pixels says you probably interact with this code every day. It's a snippet of HTML that embeds a single tiny pixel in an email. Getting an email with a tracking code spies on me. As follows: My browser requests the single-pixel image as soon as I open the mail. My email sender checks to see if Clives browser has requested that pixel. My email sender can tell when I open it.

Adding a tracking pixel to an email is easy:

<img src="URL LINKING TO THE PIXEL ONLINE" width="0" height="0">

An older example: Ellen R. Stofan and Nick Partridge wrote a chapter on Apollo 11's lunar module bailout code. This bailout code operated on the lunar module's tiny on-board computer and was designed to prioritize: If the computer grew overloaded, it would discard all but the most vital work.

When the lunar module approached the moon, the computer became overloaded. The bailout code shut down anything non-essential to landing the module. It shut down certain lunar module display systems, scaring the astronauts. Module landed safely.

22-line code

POODOO    INHINT
    CA  Q
    TS  ALMCADR

    TC  BANKCALL
    CADR  VAC5STOR  # STORE ERASABLES FOR DEBUGGING PURPOSES.

    INDEX  ALMCADR
    CAF  0
ABORT2    TC  BORTENT

OCT77770  OCT  77770    # DONT MOVE
    CA  V37FLBIT  # IS AVERAGE G ON
    MASK  FLAGWRD7
    CCS  A
    TC  WHIMPER -1  # YES.  DONT DO POODOO.  DO BAILOUT.

    TC  DOWNFLAG
    ADRES  STATEFLG

    TC  DOWNFLAG
    ADRES  REINTFLG

    TC  DOWNFLAG
    ADRES  NODOFLAG

    TC  BANKCALL
    CADR  MR.KLEAN
    TC  WHIMPER

This fun book is worth reading.

I'm a contributor to the New York Times Magazine, Wired, and Mother Jones. I've also written Coders: The Making of a New Tribe and the Remaking of the World and Smarter Than You Think: How Technology is Changing Our Minds. Twitter and Instagram: @pomeranian99; Mastodon: @clive@saturation.social.