ZERO GRACE/ZERO MALICE

Amazon's purchase of One Medical could speed up American healthcare

The U.S. healthcare industry is a 7-ton seal bleeding at sea. Predators are circling. Unearned margin: price increases relative to inflation without quality improvements. Amazon is the 11-foot megalodon with 7-inch teeth. Amazon is no longer circling... but attacking.

In 2020 dollars, per capita U.S. healthcare spending increased from $2,968 in 1980 to $12,531. The result is a massive industry with 13% of the nation's workers and a fifth of GDP.

Doctor No

In 40 years, healthcare has made progress. From 73.7 in 1980 to 78.8 in 2019, life expectancy rose (before Covid knocked it back down a bit). Pharmacological therapies have revolutionized, and genetic research is paying off. The financial return, improvement split by cost increases, is terrible. No country has expense rises like the U.S., and no one spends as much per capita as we do. Developed countries have longer life expectancies, healthier populations, and less economic hardship.

Two-thirds of U.S. personal bankruptcies are due to medical expenses and/or missed work. Mom or Dad getting cancer could bankrupt many middle-class American families. 40% of American adults delayed or skipped needed care due to cost. Every healthcare improvement seems to have a downside. Same pharmacological revolution that helped millions caused opioid epidemic. Our results are poor in many areas: The U.S. has a high infant mortality rate.

Healthcare is the second-worst retail industry in the country. Gas stations are #1. Imagine walking into a Best Buy to buy a TV and a Blue Shirt associate requests you fill out the same 14 pages of paperwork you filled out yesterday. Then you wait in a crowded room until they call you, 20 minutes after the scheduled appointment you were asked to arrive early for, to see the one person in the store who can talk to you about TVs, who has 10 minutes for you. The average emergency room wait time in New York is 6 hours and 10 minutes.

If it's bad for the customer, it's worse for the business. Physicians spend 27% of their time helping patients; 49% on EHRs. Documentation, order entry, billing, and inbox management. Spend a decade getting an M.D., then become a bureaucrat.

No industry better illustrates scale diseconomies. If we got the same return on healthcare spending as other countries, we'd all live to 100. We could spend less, live longer and healthier, and pay off the national debt in 15 years. U.S. healthcare is the worst ever.

What now? Competition is at the heart of capitalism, the worst system of its kind.

Priority Time

Amazon is buying One Medical for $3.9 billion. I think this deal will liberate society. Two years in, I think One Medical is great. When I got Covid, I pressed the One Medical symbol on my phone; a nurse practitioner prescribed Paxlovid and told me which pharmacies had it in stock.

Amazon enables the company's vision. One Medical's stock is down to $10 from $40 at the start of 2021. Last year, it lost $250 million and needs cash (Amazon has $60 billion). ONEM must grow. The service has 736,000 members. Half of U.S. households have Amazon Prime. Finally, delivery. One Medical is a digital health/physical office hybrid, but you must pick up medication at the pharmacy. Upgrade your Paxlovid delivery time after a remote consultation. Amazon's core competency means it'll happen. Healthcare speed and convenience will feel alien.

It's been a long, winding road to disruption. Amazon, JPMorgan, and Berkshire Hathaway formed Haven four years ago to provide better healthcare for their 1.5 million employees. It rocked healthcare stocks the morning of the press release, but folded in 2021.

Amazon Care is an employee-focused service. Home-delivered virtual health services and nurses. It's doing well, expanding nationwide, and providing healthcare for other companies. Hilton is Amazon Care's biggest customer. The acquisition of One Medical will bring 66 million Prime households capital, domain expertise, and billing infrastructure. Imagine:

"Alexa, I'm hot and my back hurts."

"Connecting you to a Prime doctor now."

Want to vs. Have to

I predicted Amazon entering healthcare years ago. Why? For the same reason Apple is getting into auto. Amazon's P/E is 56, double Walmart's. The corporation must add $250 billion in revenue over the next five years to retain its share price. White-label clothes or smart home products won't generate as much revenue. It must enter a huge market without scale, operational competence, and data skills.

Current Situation

Healthcare reform benefits both consumers and investors. In 2015, healthcare services had S&P 500-average multiples. The market is losing faith in public healthcare businesses' growth. Healthcare services have lower EV/EBITDA multiples than the S&P 500.

Amazon isn't the only prey-hunter. Walmart and Alibaba are starting pharmacies. Uber is developing medical transportation. Private markets invested $29 billion in telehealth last year, up 95% from 2020.

The pandemic accelerated telehealth, the immediate unlock. After the first positive Covid case in the U.S., services that had to be delivered in person shifted to Zoom... We lived. We grew. Video house calls continued after in-person visits were allowed. McKinsey estimates telehealth visits are 38 times pre-pandemic levels. Doctors adopted the technology, regulators loosened restrictions, and patients saved time. We're far from remote surgery, but many patient visits are unnecessary. A study of 40 million patients during lockdown found that for chronic disease patients, online visits didn't affect outcomes. This method of care will only improve.

Amazon's disruption will be significant and will inspire a flood of capital, startups, and consumer brands. Mark Cuban launched a pharmacy that eliminates middlemen in January. Outcome? A 90-day supply of acid-reflux medication costs $17. Medicare could have saved $3.6 billion by buying generic drugs from Cuban's pharmacy. Other apex predators will look at different limbs of the carcass for food. Nike could enter healthcare via orthopedics, acupuncture, and chiropractic. LVMH, L'Oréal, and Estée Lauder may launch global plastic surgery brands. Hilton and Four Seasons may open hospitals. Lennar and Pulte could build "Active Living" communities that Nana would leave feet first, avoiding the expense and tragedy of dying among strangers.

Risks

Privacy matters: HIV status is different from credit card and billing address. Most customers (60%) feel fine sharing personal health data via virtual technologies, though. Unavoidable. 85% of doctors believe data-sharing and interoperability will become the norm. Amazon is the most trusted tech company for handling personal data. Not Meta: Amazon.

What about antitrust, then?

Amazon should be required to spin off AWS and/or Amazon Fulfillment and banned from promoting its own products. It should be allowed to acquire hospitals. One Medical's $3.9 billion acquisition is a drop in the bucket compared to UnitedHealth's $498 billion market valuation.

Antitrust enforcement shouldn't assume some people/firms are good/bad. It should recognize that competition is good and focus on making markets more competitive in each deal. The FTC should force asset divestitures in e-commerce, digital marketing, and social media. These companies can also promote competition in a social ill.

U.S. healthcare makes us fat, depressed, and broke. Competition has produced massive value and prosperity across most of our economy.

Dear Amazon … bring it.

My colleague Ilana Ovental and I examined pandemic media coverage of education at the end of last year. That analysis examined coverage changes. We tracked K-12 topic attention over the previous two decades using Lexis Nexis. See the results here.

I was struck by how cleanly the past two decades can be divided up into three (or three and a half) eras of school reform—a framing that can help us comprehend where we are and how we got here. In a time when epidemic, political unrest, frenetic news cycles, and culture war can make six months seem like a lifetime, it's worth pausing for context.

If you look at the peaks in the above graph, the 21st century looks to be divided into periods. The decade-long rise and fall of No Child Left Behind began during the Bush administration. In a few years, NCLB became the dominant K-12 framework. Advocates and financiers discussed achievement gaps and measured success with AYP.

NCLB collapsed under the weight of rigorous testing, high-stakes accountability, and a race to the bottom by the Obama years. Obama's Race to the Top garnered attention, but its most controversial component, the Common Core State Standards, rose quickly.

Academic standards replaced assessment and accountability. New math, fiction, and standards were hotly debated. Reformers and funders chanted worldwide benchmarking and systems interoperability.

We went from federally driven testing and accountability to government encouraged/subsidized/mandated (pick your verb) reading and math standardization. Last year, Checker Finn and I wrote The End of School Reform? The 2010s populist wave thwarted these objectives. The Tea Party, Occupy Wall Street, Black Lives Matter, and Trump/MAGA all attacked established institutions.

Consequently, once the Common Core fell, no alternative program emerged. Instead, school choice—the policy most aligned with populist suspicion of institutional power—reached a half-peak. This was less a case of choice erupting to prominence than of continuous growth in a vacuum. Even with Betsy DeVos' determined, controversial efforts, school choice received only half the media attention that NCLB and Common Core did at their heights.

Recently, culture clash-fueled attention to race-based curriculum and pedagogy has exploded (all playing out under the banner of critical race theory). This third, culture war-driven wave may not last as long as the other waves.

Even though I don't understand it, the move from slow-building policy debate to fast cultural confrontation over two decades is notable. I don't know if it's cyclical or permanent, or if it's about schooling, media, public discourse, or all three.

One final thought: After doing this work for decades, I've noticed how smoothly advocacy groups, associations, and other activists adapt to the zeitgeist. In 2007, mission statements focused on accomplishment disparities. Five years later, they promoted standardization. Language has changed again.

Part of this is unavoidable and healthy. Chasing currents can also make companies look unprincipled, promote scepticism, and keep them spinning the wheel. Bearing in mind that these tides ebb and flow may give educators, leaders, and activists more confidence to hold onto their values and pause when they feel compelled to follow the crowd.

Only two of the following three options can be achieved: consistency, availability, and partition tolerance

Someone told me that growing from 30 to 60 is the biggest adjustment for a team or business.

I remember thinking, That's random. Each company is unique. I've seen teams of all types confront the same issues during development periods. With new enterprises starting every year, we should be better at navigating growing difficulties.

As a team grows, its processes and systems break down, requiring reorganization or declining results. Why always? Why isn't there a perfect scaling model? Why hasn't that been found?

The Three Things Productive Organizations Must Have

Any company should be efficient and productive. Three items are needed:

First, it must verify that no two team members have conflicting information about the roadmap, strategy, or any input that could affect execution. Teamwork is required.

Second, it must ensure that everyone can receive the information they need from everyone else quickly, especially as teams become more specialized (an inevitability in a developing organization). It requires everyone's accessibility.

Third, it must ensure that the organization can operate efficiently even if a piece is unavailable. It's partition-tolerant.

From my experience with the many teams I've been on, invested in, or advised, achieving all three is nearly impossible. Why a perfect organization model cannot exist is clear after analysis.

The CAP Theorem: What is it?

Eric Brewer of Berkeley discovered the CAP Theorem, which argues that a distributed data storage should have three benefits. One can only have two at once.

The three benefits are consistency, availability, and partition tolerance, which implies that even if part of the system is offline, the remainder continues to work.

This notion is usually applied to computer science, but I've realized it's also true for human organizations. In a post-COVID world, many organizations are hiring non-co-located staff as they grow. CAP Theorem is more important than ever. Growing teams sometimes think they can develop ways to bypass this law, dooming themselves to a less-than-optimal team dynamic. They should adopt CAP to maximize productivity.

Path 1: Consistency and availability equal no tolerance for partitions

Let's imagine you want your team to always be in sync (i.e., for someone to be the source of truth for the latest information) and to be able to share information with each other. Only division into domains will do.

Numerous developing organizations do this, especially after the early stage (say, 30 people) when everyone may wear many hats and be aware of all the moving elements. After a certain point, it's tougher to keep generalists aligned than to divide them into specialized tasks.

In a specialized, segmented team, leaders optimize consistency and availability (i.e. every function is up-to-speed on the latest strategy, no one is out of sync, and everyone is able to unblock and inform everyone else).

Partition tolerance suffers. If any component of the organization breaks down (someone goes on vacation, quits, underperforms, or Gmail or Slack goes down), productivity stops. There's no way to give the team stability, availability, and smooth operation during a hiccup.

Path 2: Partition Tolerance and Availability = No Consistency

Some businesses avoid relying too heavily on any one person or sub-team by maximizing availability and partition tolerance (the organization continues to function as a whole even if particular components fail). Only redundancy can do that. Instead of specializing each member, the team spreads expertise so people can work in parallel. I switched from Path 1 to Path 2 because I realized too much reliance on one person is risky.

What happens after redundancy? Unreliable. The more people may run independently and in parallel, the less anyone can be the truth. Lack of alignment or updated information can lead to people executing slightly different strategies. So, resources are squandered on the wrong work.

Path 3: Partition and Consistency "Tolerance" equates to "absence"

The third, least-used path stresses partition tolerance and consistency (meaning answers are always correct and up-to-date). In this organizational style, it's most critical to maintain the system operating and keep everyone aligned. No one is allowed to read anything without an assurance that it's up-to-date (i.e. there’s no availability).

Always short-lived. In my experience, a business that prioritizes quality and scalability over speedy information transmission can get bogged down in heavy processes that hinder production. Large-scale, this is unsustainable.

Accepting CAP

When two puzzle pieces fit, the third won't. I've watched developing teams try to tackle these difficulties, only to find, as their ancestors did, that they can never be entirely solved. Idealized solutions fail in reality, causing lost effort, confusion, and lower production.

As teams develop and change, they should embrace CAP, acknowledge there is a limit to productivity in a scaling business, and choose the best two-out-of-three path.

We may never tap again in ten years.

I discussed styling websites and web apps on smartwatches in my earlier article on W3C standardization.

The Parallax Chronicles

Section containing examples and flying objects

Another intriguing Working Draft I found applies to all devices, including smartphones.

These pages may have something intriguing. Take your time. Return after scrolling:

• Exhibit 1

• Exhibit 2

• Exhibit 3

What connects these three pages?

JustinWick at English Wikipedia • CC-BY-SA-3.0

Scroll-linked animation, commonly called parallax, is the effect.

WordPress theme developers' quick setup and low-code tools made the effect popular around 2014.

Parallax: Why Designers Love It

The chapter that your designer shouldn't read

Online video playback required searching, scrolling, and clicking ten years ago. Scroll and click four years ago.

Some video sites let you swipe to autoplay the next video from an endless list.

UI designers create scrollable pages and apps to accommodate the behavioral change.

Web interactivity used to be mouse-based. Clicking a button opened a help drawer, and hovering animated it.

However, a large page with more material requires fewer buttons and less interactiveness.

Designers choose scroll-based effects. Design and frontend developers must fight the trend but prepare for the worst.

How to Create Parallax

The component that you might want to show the designer

JavaScript-based effects track page scrolling and apply animations.

Javascript libraries like lax.js simplify it.

Using it needs a lot of human mathematical and physical computations.

Your asset library must also be prepared to display your website on a laptop, television, smartphone, tablet, foldable smartphone, and possibly even a microwave.

Overall, scroll-based animations can be solved better.

CSS Scroll-linked Animations

CSS makes sense since it's presentational. A Working Draft has been laying the groundwork for the next generation of interactiveness.

The new CSS property scroll-timeline powers the feature, which MDN describes well.

Before testing it, you should realize it is poorly supported:

Firefox 103 currently supports it.

There is also a polyfill, with some demo examples to explore.

Summary

Web design was a protracted process. Started with pages with static backdrop images and scrollable text. Artists and designers may use the scroll-based animation CSS API to completely revamp our web experience.

It's a promising frontier. This post may attract a future scrollable web designer.

Ps. I have created flashcards for HTML, Javascript etc. Check them out!

If you're not genuine, you'll be revealed.

Sam Bankman-Fried (SBF) was called the Cryptocurrency Warren Buffet.

No wonder.

SBF's trading expertise, Blockchain knowledge, and ability to construct FTX attracted mainstream investors.

He had a fantastic worldview, donating much of his riches to charity.

As the onion layers peel back, it's clear he wasn't the altruistic media figure he portrayed.

SBF's mistakes were disastrous.

• Customer deposits were traded and borrowed by him.

• With ten other employees, he shared a $40 million mansion where they all had polyamorous relationships.

• Tone-deaf and wasteful marketing expenditures, such as the $200 million spent to change the name of the Miami Heat stadium to the FTX Arena

• Democrats received a $40 million campaign gift.

• And now there seems to be no regret.

FTX was a 32-billion-dollar cryptocurrency exchange.

It went bankrupt practically overnight.

SBF, FTX's creator, exploited client funds to leverage trade.

FTX had $1 billion in customer withdrawal reserves against $9 billion in liabilities in sister business Alameda Research.

Bloomberg Billionaire Index says it's the largest and fastest net worth loss in history.

It gets worse.

SBF's net worth is $900 Million, however he must still finalize FTX's bankruptcy.

SBF's arrest in the Bahamas and SEC inquiry followed news that his cryptocurrency exchange had crashed, losing billions in customer deposits.

A journalist contacted him on Twitter D.M., and their exchange is telling.

His ideas are revealed.

Kelsey Piper says they didn't expect him to answer because people under investigation don't comment.

Bankman-Fried wanted to communicate, and the interaction shows he has little remorse.

SBF talks honestly about FTX gaming customers' money and insults his competition.

Reporter Kelsey Piper was outraged by what he said and felt the mistakes SBF says plague him didn't evident in the messages.

Before FTX's crash, SBF was a poster child for Cryptocurrency regulation and avoided criticizing U.S. regulators.

He tells Piper that his lobbying is just excellent PR.

It shows his genuine views and supports cynics' opinions that his attempts to win over U.S. authorities were good for his image rather than Crypto.

SBF’s responses are in Grey, and Pipers are in Blue.

It's unclear if SBF cut corners for his gain. In their Twitter exchange, Piper revisits an interview question about ethics.

SBF says, "All the foolish sh*t I said"

SBF claims FTX has never invested customer monies.

Piper challenged him on Twitter.

While he insisted FTX didn't use customer deposits, he said sibling business Alameda borrowed too much from FTX's balance sheet.

He did, basically.

When consumers tried to withdraw money, FTX was short.

SBF thought Alameda had enough money to cover FTX customers' withdrawals, but life sneaks up on you.

SBF believes most exchanges have done something similar to FTX, but they haven't had a bank run (a bunch of people all wanting to get their deposits out at the same time).

SBF believes he shouldn't have consented to the bankruptcy and kept attempting to raise more money because withdrawals would be open in a month with clients whole.

If additional money came in, he needed $8 billion to bridge the creditors' deficit, and there aren't many corporations with $8 billion to spare.

Once clients feel protected, they will continue to leave their assets on the exchange, according to one idea.

Kevin OLeary, a world-renowned hedge fund manager, says not all investors will walk through the open gate once the company is safe, therefore the $8 Billion wasn't needed immediately.

SBF claims the bankruptcy was his biggest error because he could have accumulated more capital.

Final Reflections

Sam Bankman-Fried, 30, became the world's youngest billionaire in four years.

Never listen to what people say about investing; watch what they do.

SBF is a trader who gets wrecked occasionally.

Ten first-time entrepreneurs ran FTX, screwing each other with no risk management.

It prevents opposing or challenging perspectives and echo chamber highs.

Twitter D.M. conversation with a journalist is the final nail.

He lacks an experienced crew.

This event will surely speed up much-needed regulation.

It's also prompted cryptocurrency exchanges to offer proof of reserves to calm customers.