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.

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.

You have to use it.

Chat-GPT is a revolution.

All social media outlets are discussing it. How it will impact the future and different things.

True.

I've been using Chat-GPT for a few days, and it's a rare revolution. It's amazing and will only improve.

I asked Chat-GPT about the best non-fiction books. It advised this, albeit results rely on interests.

The Immortal Life of Henrietta Lacks

by Rebecca Skloot

Science, Biography

A impoverished tobacco farmer dies of cervical cancer in The Immortal Life of Henrietta Lacks. Her cell strand helped scientists treat polio and other ailments.

Rebecca Skloot discovers about Henrietta, her family, how the medical business exploited black Americans, and how her cells can live forever in a fascinating and surprising research.

You ought to read it.

1. if you want to discover more about the past of medicine.

2. if you want to discover more about American history.

Bad Blood: Secrets and Lies in a Silicon Valley Startup

by John Carreyrou

Tech, Bio

Bad Blood tells the terrifying story of how a Silicon Valley tech startup's blood-testing device placed millions of lives at risk.

John Carreyrou, a Pulitzer Prize-winning journalist, wrote this book.

Theranos and its wunderkind CEO, Elizabeth Holmes, climbed to popularity swiftly and then plummeted.

You ought to read it.

1. if you are a start-up employee.

2. specialists in medicine.

The Power of Now: A Guide to Spiritual Enlightenment

by Eckhart Tolle

Self-improvement, Spirituality

The Power of Now shows how to stop suffering and attain inner peace by focusing on the now and ignoring your mind.

The book also helps you get rid of your ego, which tries to control your ideas and actions.

If you do this, you may embrace the present, reduce discomfort, strengthen relationships, and live a better life.

You ought to read it.

1. if you're looking for serenity and illumination.

2. If you believe that you are ruining your life, stop.

3. if you're not happy.

The 7 Habits of Highly Effective People

by Stephen R. Covey

Profession, Success

The 7 Habits of Highly Effective People is an iconic self-help book.

This vital book offers practical guidance for personal and professional success.

This non-fiction book is one of the most popular ever.

You ought to read it.

1. if you want to reach your full potential.

2. if you want to discover how to achieve all your objectives.

3. if you are just beginning your journey toward personal improvement.

Sapiens: A Brief History of Humankind

by Yuval Noah Harari

Science, History

Sapiens explains how our species has evolved from our earliest ancestors to the technology age.

How did we, a species of hairless apes without tails, come to control the whole planet?

It describes the shifts that propelled Homo sapiens to the top.

You ought to read it.

1. if you're interested in discovering our species' past.

2. if you want to discover more about the origins of human society and culture.

Consider yourself lucky if your last FAANG interview was rejected.

FAANG—Facebook, Apple, Amazon, Netflix, Google

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

These big companies offer many benefits.

1. large salaries and benefits

2. Prestige

3. high expectations for both you and your coworkers.

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

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

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

Little fish in a vast ocean

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

You may work on a small, unnoticed product part.

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

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

The power imbalance is frustrating.

What you can do about it

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

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

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

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

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

An outdated piece of technology can take years to update.

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

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

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

What you can do about it

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

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

Most managers spend their entire day in consecutive meetings.

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

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

Misunderstandings and stress can result.

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

What you can do about it

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

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

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

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

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

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

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

Google may become your surname.

Workplaces are not families.

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

Many employees stayed too long. Though depressed and suicidal.

What you can do about it

1. Your life is not worth a company.

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

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

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

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

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

Companies may pay more than FAANGs. Do your research.

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

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

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

Read both sides before signing the big offer letter.

I read 1k+ page 3AC liquidation documentation so you don't have to. Also sharing revised Celsius recovery plans.

3AC's liquidation documents:

Someone disclosed 3AC liquidation records in the BVI courts recently. I'll discuss the leak's timeline and other highlights.

Three Arrows Capital began trading traditional currencies in emerging markets in 2012. They switched to equities and crypto, then purely crypto in 2018.

By 2020, the firm had $703mm in net assets and $1.8bn in loans (these guys really like debt).

The firm's net assets under control reached $3bn in April 2022, according to the filings. 3AC had $600mm of LUNA/UST exposure before May 9th 2022, which put them over.

LUNA and UST go to zero quickly (I wrote about the mechanics of the blowup here). Kyle Davies, 3AC co-founder, told Blockchain.com on May 13 that they have $2.4bn in assets and $2.3bn NAV vs. $2bn in borrowings. As BTC and ETH plunged 33% and 50%, the company became insolvent by mid-2022.

3AC sent $32mm to Tai Ping Shen, a Cayman Islands business owned by Su Zhu and Davies' partner, Kelly Kaili Chen (who knows what is going on here).

3AC had borrowed over $3.5bn in notional principle, with Genesis ($2.4bn) and Voyager ($650mm) having the most exposure.

Genesis demanded $355mm in further collateral in June.

Deribit (another 3AC investment) called for $80 million in mid-June.

Even in mid-June, the corporation was trying to borrow more money to stay afloat. They approached Genesis for another $125mm loan (to pay another lender) and HODLnauts for BTC & ETH loans.

Pretty crazy. 3AC founders used borrowed money to buy a $50 million boat, according to the leak.

Su requesting for $5m + Chen Kaili Kelly asserting they loaned $65m unsecured to 3AC are identified as creditors.

Celsius:

This bankruptcy presentation shows the Celsius breakdown from March to July 14, 2022. From $22bn to $4bn, crypto assets plummeted from $14.6bn to $1.8bn (ouch). $16.5bn in user liabilities dropped to $4.72bn.

In my recent post, I examined if "forced selling" is over, with Celsius' crypto assets being a major overhang. In this presentation, it looks that Chapter 11 will provide clients the opportunity to accept cash at a discount or remain long crypto. Provided that a fresh source of money is unlikely to enter the Celsius situation, cash at a discount or crypto given to customers will likely remain a near-term market risk - cash at a discount will likely come from selling crypto assets, while customers who receive crypto could sell at any time. I'll share any Celsius updates I find.

Conclusion

Only Celsius and the Mt Gox BTC unlock remain as forced selling catalysts. While everything went through a "relief" pump, with ETH up 75% from the bottom and numerous alts multiples higher, there are still macro dangers to equities + risk assets. There's a lot of wealth waiting to be deployed in crypto ($153bn in stables), but fund managers are risk apprehensive (lower than 2008 levels).

We're hopefully over crypto's "bottom," with peak anxiety and forced selling behind us, but we may chop around.

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