Healthcare 2026: AI Doctors, GLP-1s, and Insurance Defection

Out-of-Pocket is a healthcare education company founded by Nikhil Krishnan that helps people understand how healthcare works and how to navigate it in practice. In this episode, a16z investing partner Jay Rughani and Nikhil discuss why health insurance is losing its role as the default way people access care. They explain how rising costs are pushing more consumers to pay out of pocket for diagnostics, preventive care, and navigation. The conversation also looks at what this shift means for startups, AI-powered tools, regulation, and access as healthcare continues to move beyond insurance.

• 0:00Speaker 00

  If you go into like our health insurance subreddit, extremely common question now of just, hey, should I just not get health insurance at all? These are my premiums. This is kind of what I'm paying. This is kind of the drug I need or blah, blah, blah. And for a lot of people, that answer is actually probably no.

• 0:16Speaker 01

  The healthcare system that we have today in the US is drastically supply constrained. 23 million Americans work in healthcare, yet we've got long wait times. 100 million people plus don't have access to a primary care doc. 40 day plus wait times to see a doc if you can.

• 0:33Speaker 00

  The existing healthcare system, they really want to create standardized care for people, right? And standardized guidelines to make medicine good at the median level for everybody, right? But at the same time, people want more agency in their healthcare in some capacity. No one wants to be told like, hey, just wait and see.

• 1:02Speaker 02

  What happens when Americans start rebuilding healthcare outside the traditional system? Not because they reject healthcare, but because the way care is accessed, priced and delivered no longer matches how people actually use it. For years, the US healthcare system has been organized around insurance. The Affordable Care Act expanded coverage and brought the uninsured rate down. And for a time, the system appeared to be stabilizing. But rising premiums, high deductibles and limited access have left many consumers paying more while using care less. In response, behavior is changing. Some people are opting out of insurance entirely. Others keep coverage but increasingly pay out of pocket for diagnostics, preventative care, memberships and digital tools that offer speed, clarity and control. Care is moving towards proactive screening,

• 1:46Speaker 02

  monitoring and navigation, often outside traditional clinical settings. This shift is not just about consumer frustration. It's reshaping the healthcare stack itself. New companies are emerging to help people find care, price services, interpret results and manage health over time. AI is beginning to play a role in triage, navigation, diagnostics and clinical workflows, even as regulation and reimbursement continue to lag behind consumer demand. At the same time, core tensions remain unresolved. Emergencies don't disappear when care moves outside insurance. Costs shift across the system. Questions around access, equity, and sustainability become harder to ignore as healthcare fragments into parallel pathways. Today, we examine how consumer behavior, technology, and economics are converging

• 2:31Speaker 02

  to reconfigure U.S. healthcare. We discuss why insurance defection is happening, how cash pay and proactive care are expanding, where founders are building in response, and what this transition could mean for the long-term structure of care. A60Z Health and Bio Partner Jay Rughani sits down with Nikhil Krishnan, founder of Out of Pocket, to explore how healthcare is being rebuilt piece by piece outside the traditional system.

• 2:55Speaker 01

  Nikhil, what's happening? What's up, man? So, healthcare is off to a hot start in 2026. JP Morgan always kicks us off in a good place. The group chats are buzzing. Of course. OpenAI dropped some new healthcare news. They got a health app. Totally. Anthropic 2. Anthropic 2, PHR's are back. President Trump announced the Great Healthcare Plan today. I haven't read it yet, so please don't ask me any questions. I was gonna quiz you on that. Utah is letting AI prescribe medications. Of course. That's happening. FDA rolling back regulations on wearables. Trials, wearables, we're doing Bayesian trials now. We're doing it all. Crazy. And we have a new food pyramid. We do. So, lots to talk about. It's more like a downward arrow now.

• 3:40Speaker 01

  Yeah, yeah, yeah. It's inverse pyramid. I ran your 2025 predictions through Claude. Of course. You got a 7.623 out of 10. Already for the year? It's only been two weeks. No, last year. I put last year's predictions. Hey, that's pretty good. It's really good, actually. It's too specific to mean anything. Totally. But it's good. Nice. So, it sounded good. But I thought you went spicier this year. I thought your 2026 were spicier. So, we're here to debate them. Okay, let's fight. Let's fight right now, and then we can check the Kalshi prediction market after to see who won. We gotta put money where this is. It's not a predictions post anymore unless you have some Kalshi, you know, some money in a prediction market. If you don't have dollars at stake, what are you even doing? Why are you even doing it? Yeah, exactly.

• 4:24Speaker 01

  All right, so let's start with your prediction on health insurance defection. I've got them all up here. Cool, yeah. I think that sets the stage on where we think healthcare dollars will flow in 26, and then will flow into the others. So. One of your predictions says that uninsured rates explode.

• 4:40Speaker 00

  Sure.

• 4:41Speaker 01

  The uninsured rate explodes and the second order effects. So people refuse to play the healthcare insurance game.

• 4:47Speaker 00

  Yeah.

• 4:47Speaker 01

  Defecting from the system.

• 4:49Speaker 00

  Sure.

• 4:49Speaker 01

  The rate of uninsured people will skyrocket to 15%, leading to consequences like flooded emergency rooms, spiking insurance premiums and more cash pay options.

• 4:59Speaker 00

  Exactly.

• 5:00Speaker 01

  So today, the uninsured rate is around 9.5%. I had to look that up. As low as 3% in Massachusetts.

• 5:07Speaker 00

  Mm-hmm.

• 5:08Speaker 01

  18% in Texas.

• 5:09Speaker 00

  Wow, I learned something.

• 5:10Speaker 01

  Yeah. In 2009, 2010, pre Affordable Care Act, it was around 15%, which is 15, 16%, which is where you projected it. So 15 years of progress unwinding in 12 months. If you define that as progress. And the whole country is about to look like Texas. So lay that one out for us. What made you think that?

• 5:30Speaker 00

  Well, I mean, it's a combination of things, right? Like, at the time when I wrote this, obviously, like, premium subsidies were still a big debate. So it was unclear where that would sort of shape up. And, you know, where I live in New York, for example, like, we have a extremely high-cost insurance, individual exchange market, right? And this for a whole host of reasons that we don't have to get into. But it seemed like the premiums were going to spike across the board for the individual exchange.

• 5:57Speaker 01

  Right.

• 5:57Speaker 00

  On top of that, small group insurance is kind of going through this weird thing right now, where, one, if you have relatively less sick people, you're like, hey, why am I subsidizing the pool of the more sick people? Let me, like, exit it through, you know, things like level funding or any of these other things, or even just not offering insurance at all, right? That's now an option because the labor market has so far tilted to employers that, you know, if you're below 50 people, you don't have to offer insurance either, right? So I think a lot of people with healthier, a lot of employers with healthier employees will be like, hey, I don't want to subsidize these sicker people. And then the employers with more sick employees then are left in their own pool. Those premiums skyrocket.

• 6:41Speaker 00

  And then the employers in that pool also have the option to not. So basically... I think there's a lot of reasons why people will eventually just say, hey, should I really be paying? You know, I don't remember what the average premium is, but you know, 12,000 plus dollars a year for a family with a deductible on top, but I don't even use health insurance at all, right? People are getting squeezed, obviously, and you know, their individual wallet share and all that kind of stuff. So they're going to be asking themselves, and if you go on the like, our health insurance subreddit, extremely common question now of just, hey, you know, should I just not get health insurance at all? Right? These are my premiums. This is kind of what I'm paying. This is kind of the drug I need or blah, blah, blah. And for a lot of people, that answer is actually probably no.

• 7:24Speaker 00

  If you think about it for a second, if I were like, be really rational about this and I'm thinking, okay, I'm a relatively healthy person with no expected procedures or medical things this year, like nothing planned. If I believe that, then, and my premiums, let's say on the individual market are 550 a month, which is like, is in New York, plus on top of that, probably like a 5K, 6K deductible, right? Now suddenly like, you just do the math, right? It's 12 times 600 plus a 5K deductible. So before even anything is covered at that point, right? You are paying like 10, 15 grand, depending on who you are. And I'm really just protecting against catastrophes, cancer, car crash, whatever.

• 8:09Speaker 00

  Then it's like, expected probability of that thing happening is like relatively low. And so I can totally see for a lot of people saying, it's just not worth it for me.

• 8:17Speaker 01

  So, so let's talk about the likelier that it's going to happen, but almost just rewind the clock a little bit.

• 8:22Speaker 00

  Sure.

• 8:22Speaker 01

  Is this a good thing? Lay out the arguments for both sides.

• 8:25Speaker 00

  I mean, the con is sort of obvious, which is that I think a lot of people who are not good at guessing their own risk will have something happen to them and then end up in a hospital and have to pay a ton of money that they just don't have. Right? So that's one con is that coverage for people goes down and something bad happens to them and then they have to deal with it, right? So that part's bad. And also I think that depending on what your view is on should we have health insurance at all? Then if you believe that we should have health insurance in health insurance industry as in general, then this totally fractures like the risk pool makes our economics all wonky,

• 9:06Speaker 00

  blah, blah, blah, and will probably just lead to a handful of payers that do the whole country.

• 9:11Speaker 01

  Yeah.

• 9:11Speaker 00

  Four or five, right? You're already seeing this right now. Smaller health insurance companies getting bought by larger ones, like happening at rapid scale. A lot of the Blues plans are consolidating, all this kind of stuff.

• 9:21Speaker 01

  Yeah.

• 9:21Speaker 00

  So if you believe we should have a competitive health insurance ecosystem, this kind of defeats that purpose a little bit. The pros of it are if you believe more in a consumer-directed healthcare system in some capacity, where hey, people get money and they should just use that money to pay for services they think are worthwhile to them, then this is sort of the like means to do that, right? If people feel more healthcare costs directly, they will be better shoppers, they will, people will try to cater to them more, so there's a better experience and all that kind of stuff. So, I mean, I think a lot of people probably rightfully make the argument that like having a third-party payer is one of the reasons that costs are so inflated.

• 10:05Speaker 00

  It's one of the reasons the experience is so bad when you're not the direct customer, right?

• 10:09Speaker 01

  Yeah.

• 10:09Speaker 00

  So those are the pros and cons of it. Really just depends, there's no right and wrong. It just depends on what your ideology and what coverage should look like. It's your earlier point about Affordable Care Act before and after, right? Like, one of the beliefs was we should have a competitive health insurance market on the marketplace.

• 10:24Speaker 01

  Yeah.

• 10:25Speaker 00

  And they will, if everyone is on the same marketplace, then they'll compete for people and it'll function like a normal marketplace for a whole host of reasons that didn't happen. So now the question is, should we go back or should we try and double down and fix it? And not clear.

• 10:39Speaker 01

  Yeah, I think there's, if I were to steel man the libertarian case, which is sort of what you talked about around, around the free market, let the consumers kind of choose. It's basically saying, some people will say, finally, the market is working. People are defecting because the product is bad. Let them defect.

• 10:56Speaker 00

  Sure.

• 10:57Speaker 01

  The product will get better. If they want those customers, they'll get them back, or they won't, and people are voting with their wallets.

• 11:04Speaker 00

  Sure.

• 11:04Speaker 01

  So that's one side. The other side is basically the, you know, the free rider counter argument. We kind of heard this back in 2009, 2010, ahead of the Affordable Care Act was people would go and say, I'm going to go without in health insurance, knowing that there's a federal law that effectively requires hospitals to take care of them.

• 11:24Speaker 00

  Yep.

• 11:25Speaker 01

  And, you know, the belief or the worry was that people would go out, go would sort of stay away from the traditional care, preventative care, and just wait until things get really bad. And then they end up in the hospital and it's paid for.

• 11:37Speaker 00

  Yeah.

• 11:38Speaker 01

  ER is the most expensive side of service. It's the least affordable way we can deliver all kinds of healthcare.

• 11:44Speaker 00

  Yep.

• 11:45Speaker 01

  This increases costs for everyone. Hospitals have to pay for it. And the uninsured effectively result in all this uncompensated care that we inadvertently pay for anyways.

• 11:54Speaker 00

  Totally.

• 11:54Speaker 01

  In higher prices. And so overall, you know, it makes the system work.

• 11:58Speaker 00

  Sure.

• 11:59Speaker 01

  You think we're going to have the free rider problem again with this? Or is this time, does this time feel different?

• 12:05Speaker 00

  I mean, we'll probably still have that problem, right? If people don't have insurance and they get sick, it's not like they're going to stay home and just ride it out. They're going to go to the emergency department, obviously.

• 12:15Speaker 01

  Right.

• 12:15Speaker 00

  So we're definitely going to have that. I do think that, you know, there's like a bigger, I think the main ideological question is like, how do you think we as a country should treat catastrophes in healthcare?

• 12:27Speaker 01

  Yeah.

• 12:27Speaker 00

  Right?

• 12:28Speaker 01

  Yeah.

• 12:28Speaker 00

  Like, I think a lot of the stuff that people talk about when they're like, hey, people vote for their feet or want to go, is shoppable, planable things, right? And that totally makes sense. But what do you do with a person who gets in a car crash, right? People always make the argument of healthcare can't be shoppable because people aren't going to shop for an ED, you know, they're not going to be on the emergency department shopping for things. But that's a really specific case.

• 12:52Speaker 01

  The highest acuity.

• 12:53Speaker 00

  Exactly.

• 12:54Speaker 01

  Really bad, expensive stuff.

• 12:55Speaker 00

  Yeah. And so, you know, if you look at other countries' models, for example, right? Like Singapore maybe is the most common example here.

• 13:02Speaker 01

  Yeah.

• 13:02Speaker 00

  They try to separate those, right? Like, they try to make shoppable services more of a cash pay experience with their, you know, their version of what looks like an HSA. And then the government covers more catastrophic things, right? Cancers and inpatient and all this kind of stuff, right? So maybe actually this is us speedrunning to a system like that. Where you're like, okay, hey, we got a bunch of cash pay patients. They're also about to show up to these higher acuity places. And we need to figure out a way to cover them. And we need a scheme to do that, right? In some capacity, so.

• 13:33Speaker 01

  You could also argue that the goalpost has moved in the culture around health. There's clearly a greater cultural movement around health right now. We've got Maha. Consumers are spending more out of pocket for health. Alcohol sales are down, supplement sales are up, you know? And so.

• 13:53Speaker 00

  We're not taking, we're not drinking alcohol. We are injecting peptides.

• 13:56Speaker 01

  Yeah, exactly. We'll get to peptides. We'll get to peptides. You know, one question that, that I think a lot about in comparing this to the kind of free rider problem that people talked about a lot in 09 and 2010 is, are these actually different populations? There's one population, which is the proactive health crowd. You know, higher income, they're buying supplements. They're on, you know, they're buying GLP ones out of pocket. They've got an Aura ring, a Function Health membership, a council membership. They're doing all the things.

• 14:27Speaker 00

  All your friends.

• 14:28Speaker 01

  Yeah, exactly. They're working with everyone. You know, they were already insured and they're likely going to stay insured, but then they're doing these extra things out of pocket. And then there's the newly uninsured that you're arguing is sort of accelerating. People are losing coverage because subsidies expired, because the big beautiful bill had Medicaid cuts. And now they can't afford it anymore. And we're not doing a good job as a country, taking care of those people. What do you think of that distinction?

• 14:57Speaker 00

  I mean, I think at the end of the day, everyone wants to be healthy, right? It's just the way they define that is a little different, right? I think there's a group of people, probably again, on the higher income scale, who are like, I don't feel like I'm being taken care of because there's, you know, I'm not being monitored, for example, right? Like, the healthcare system is sort of not designed for my view of how I think healthcare should be. And so I am opting out into a separate system that I think more aligns with my view. That is more consumption, you know, like in just, I want to be able to consume more healthcare. And this is like the way to do it, more lab tests, more MRIs, whatever.

• 15:31Speaker 01

  Right.

• 15:32Speaker 00

  I think if you are lower income, you still obviously want to be healthy. No one like that is still the goal, but I think the problem set is a little bit different. Right. Which is I don't want to have to take off work to do a doctor's visit for just a prescription refill. For example, or my kid is sick and I just need the answer to what is happening here. Right. Or the drug I normally call take costs X amount now. How do I get it for cheaper? Right? I don't think that's maybe the problem set is a little different, but the end goal is still the same. It's just like the way they think, the way people think about healthcare, about what is good health. It's just going to be, you know, different between those groups, but they still want, everyone wants the same thing.

• 16:13Speaker 00

  They want healthcare for cheaper or actually, you know, one thing is that I think is very common is everyone wants more transparency on the pricing.

• 16:19Speaker 01

  Yeah.

• 16:20Speaker 00

  There's like, hey, I think I need to go to the hospital, but I can't do a hundred thousand dollar bill. Right. Or I want to get lab tests done, but like, no one is telling me how much it costs. If I like go to the hospital to do that. Right?

• 16:33Speaker 01

  Right.

• 16:33Speaker 00

  So everyone wants price transparency and I think the cash pay market on both ends try to serve that.

• 16:40Speaker 01

  You think there's going to be a third category that emerges here between those two camps? As an example, a member of the middle class who could afford, who could afford insurance, but chooses to go uninsured, they probably would have got health. They probably, they either work for a very small employer and maybe doesn't offer healthcare or they, you know, work for themselves and they would have bought on the exchange as an example. And they're going to bet on cash pay plus proactive health and risk it. Because that would be a third category in between these two. Do you think that's where the growth in uninsured comes from?

• 17:15Speaker 00

  So you know what health sharing ministry is?

• 17:17Speaker 01

  So this is like the first.

• 17:18Speaker 00

  Explains this is interesting. So for people who don't know what this is, it's basically instead of health insurance as you know it, which is A, I pay premiums and into this pool. And then when things happen, they pay out to other people. In health sharing ministries, the high level is you preload a wallet essentially with something that looks like premiums, but it's technically not premiums. And then when other members have a hospital bill that happens, people contribute from that wallet to pay for the hospital bills. So it's a little bit more of a crowd, almost like crowdfunding for healthcare, but amongst a specific pool of people that are essentially pre-vetted before they come. So those are typically much cheaper, and this for a bunch of reasons, right?

• 18:02Speaker 00

  One, they can do things that plans used to be able to do pre-affordable care act, deny people based on pre-existing conditions, right? So their risk pool is much better, right, as a whole? And also, they don't have the same regulatory requirements of, hey, you have to have a bunch of capital on your book so you don't go and solve it when this happens, right? So your regulatory requirements are lower, so your cost of compliance and all that is lower too. But it's like an interesting model where you're like, hey, if I go to the hospital and get a bill and I show this to the people and then they all contribute to it. But the downside is you better hope that people are actually down and will pay for it. And I do think it's an interesting product for people who are, and when I say interesting, I don't mean like I ideologically agree with it, but I do just think it is. You're not recommending it.

• 18:46Speaker 00

  I'm not recommending it, but I do think this is, it probably addresses this middle ground a little bit where it's like, hey, like the health insurance I currently have sucks and it's not covering the things I want it to cover anyway, and it's really expensive. I'm already gambling on whether or not the insurance is going to cover me or not, which was the case for a lot of people. They're like, you know, I'm buying this and then I go and they deny my claim. There already there's a chance of that happening. I might as well try this other thing and if I can get in because I'm a healthier person, I pay less for it. So I think there's a lot of people that also just ideologically agree with that premise. So that I think becomes sort of.

• 19:25Speaker 00

  Potential for people in that middle zone.

• 19:27Speaker 01

  Yeah.

• 19:27Speaker 00

  But the infrastructure is not built for that because a lot of those people again have to go and shop for their own care.

• 19:33Speaker 01

  Yeah.

• 19:33Speaker 00

  Negotiate the bill, all this kind of stuff, which and some of these health sharing ministries offer services to help you negotiate and all this kind of stuff. But it's just also a very different model of healthcare consumption. Like it's, there's also some cultural change that happens here where people have to go and are willing to like negotiate prices with providers. That is not a normalized thing and maybe that becomes more normal.

• 19:54Speaker 01

  Yeah, that makes sense. It's interesting.

• 19:57Speaker 00

  Would you sign up for a health sharing ministry?

• 19:58Speaker 01

  I don't know. I don't know if I would actually. So I don't want our healthcare system to splinter into two groups. One group that can afford to defect from health insurance, go cash pay and run their own healthcare stack that way. And then folks that are effectively cycling through our existing healthcare system. You know, relying on charity care effectively out of pocket for the health system to pay for it. I spent a little bit of time this year studying different healthcare markets. Mexico as an example.

• 20:28Speaker 00

  Yeah.

• 20:29Speaker 01

  Has that to some extent. It's not a perfect parallel where there's one system for the rich and another system for the poor.

• 20:35Speaker 00

  Yeah.

• 20:35Speaker 01

  So that would be the, that would be the downside case that I would worry about here.

• 20:38Speaker 00

  There is also, I mean, so for one, I think the core problem with the US healthcare is just like we have too many risk pools. Right? You kind of have to choose one or the other, like having this, hey, maybe we're a little cash pay. Maybe we're a little bit pay, a little bit insurance. Some people are in employer insurance. Oh, some people are Medicare. That's kind of the core problem, right? We have to move to one or the other.

• 20:58Speaker 01

  Yeah.

• 20:59Speaker 00

  So, you know, for the ACA, the idea was we'll move everyone theoretically to this individual exchange and everyone will buy from that. That's at least they're all in the risk pool, right? And that looks more like Germany.

• 21:08Speaker 01

  Yeah.

• 21:08Speaker 00

  You could also do totally cash pay, right? Where it's like everyone is cash pay and you're just focused on that. That looks maybe more like in India, for example, or like a Singapore, if you're doing it through out splitting outpatient and inpatient.

• 21:20Speaker 01

  Yeah.

• 21:21Speaker 00

  But you have to pick one or the other, like this, like in between.

• 21:24Speaker 01

  Americans love choice. We love choice. We, everyone wants to have an option. We pay for the choice.

• 21:29Speaker 00

  This is, choice is like the worst way. It's like, it's like, it's choosing between the worst options now.

• 21:36Speaker 01

  Yeah.

• 21:36Speaker 00

  But also, on the flip side, there's, again, like, the ideological question of, do you believe that you should be able to pay for better care?

• 21:46Speaker 01

  Yeah.

• 21:46Speaker 00

  Right? And I think a lot, that question makes a lot of people really uncomfortable. Because it's like, they, they cannot reconcile internally that, oh, people can, should be able to pay for better doctors. Well, if you don't want that, and that's fine, what ends up happening is that if everyone gets access to one care system.

• 22:04Speaker 01

  Yeah.

• 22:04Speaker 00

  Then there will emerge a parallel system that allows them to do that no matter what, right? Because they'll be, they'll say, hey, I'll pay for the best doctors, cash, even if there is an existing one. And those doctors will exit, right? And that's kind of what's happening today with a concierge medicine and all this kind of stuff, right? Everyone's, hey, we want primary care physicians to be able to see everyone. It's like the great equalizer, all this kind of stuff. And then suddenly, people are like, I will pay a lot of money for you to just not do that. And then come, just take care of me, right?

• 22:32Speaker 01

  Yeah.

• 22:32Speaker 00

  So, the reality is, that's kind of already happening. I can't think of a single system, even in socialized medicine countries, like the UK, people still get private insurance. And to see, see docs with lower wait times, all this kind of stuff. Like, I don't think it's possible to actually have a system where you can't pay for better care. It just happens, it'll just emerge as an economy no matter what, unless you, unless you ban it, right? Which like, you can do, but that has its own sort of downsides to it too. Like, Canada, for example, is an example of not being able to do a parallel system. And that has its own issues, where people are like, hey, if I have a complex care thing, I'm gonna come to the US. So, I don't know, like, we gotta get comfortable with the idea that I think you have to,

• 23:16Speaker 00

  you will probably, no matter what, end up with a system where people pay for better care. You can either do that in a really convoluted way, or just do that in a straightforward way. Or do that in a way where you're more comfortable with what they choose to pay for, right? So, for example, in countries like India and stuff, you can pay for better amenities, right? Like, the nicer wards and all this kind of stuff. Like, maybe that's a more palatable way to do that, basically.

• 23:40Speaker 01

  Yeah. Yeah, it's interesting. Where is the, so if this plays out and TBD if it's 15% or 18% or 12%, but it's clear that, per the Reddit threads, which is truth.

• 23:54Speaker 00

  That's my truth.

• 23:55Speaker 01

  That's my truth. People are defecting.

• 23:57Speaker 00

  Yeah.

• 23:58Speaker 01

  What are the ripple effects for startups? If you're trying to start something, obviously the proactive health startups have an opportunity here, more cash pay spend, but what else?

• 24:07Speaker 00

  Yeah, I think also just like care navigation looks very different for this group of people.

• 24:11Speaker 01

  Totally.

• 24:12Speaker 00

  Right? I think you have to really think about, is this thing I'm doing serious enough that I need to go see a higher cost medical practitioner if you're paying out of pocket? Right? That triaging step is really different. So do you think that helping people figure out like, hey, where do I go for this? And is this actually serious enough that I need to go becomes a whole separate type of product to build, basically, compared to someone who you have insurance, you're really navigating them through their insurance, directory, coverage, whatever it is. So I think that looks very different. I think another ripple effect too is there's going to be, I think, a lot of people that try to deliver care at like

• 24:53Speaker 00

  hyper lower costs, right? So the DocTronic pilot in Utah is a good example, where I, if I remember correctly, they are doing prescription refills at $4 a pop.

• 25:04Speaker 01

  Instead of $150.

• 25:05Speaker 00

  Yes. Which, you know, that is actually pretty, that is relatively affordable. You need a prescription refill. That is like one route you can go rather than having to do a totally net new visit to the doctor, right? So I do think you'll see more of this, hey, how do we bring costs like an extremely low level, obviously using AI, using tech, using all this kind of stuff. And then the other one, which like, I think is a little interesting to think about is, you know, can you do some form of novel contracting with the existing providers for when they see people who are coming in as cash pay?

• 25:40Speaker 01

  Yeah.

• 25:40Speaker 00

  Right? Because the reality is, The providers are going to be in a tough spot, right? Where someone comes in, they have to pay cash. They don't like, you know, the, if they come in through the emergency room, they do some really expensive stuff. People leave, they're chase them down for the money and then they don't get it. Right? So the provider is in a tough spot when that happens. Can you offer really easy like bundled payments or whatever it is to people to be like, hey, if you're a cash pay person, here's what our rate is this and come through and get it. Right now, if you wanted to figure out the cash pay rate for something, you like have to go through a really weird convoluted process to do this. You call in, you'll say you're a self-pay patient and kind of like haggling. I feel like I'm like in the Indian market. You know what I mean?

• 26:25Speaker 00

  I'm just like, we're haggling back and forth and we're just like, what's up? Where are we going to be? But to maybe just make it really easy for everyone. It's like, hey, here's the bundle. Here are the services included. You can come for this. And that's going to especially be true for things like somewhat higher cost procedures and stuff like that, where it's like, if you're uninsured and you do really need that thing, here's how we can do it and here's the cost we'll pay.

• 26:46Speaker 01

  It looks more like the medical tourism market where people are coming.

• 26:50Speaker 00

  Exactly.

• 26:51Speaker 01

  But it's a local version of that. But people are coming to the US and they want to get the procedure at Mayo Clinic.

• 26:57Speaker 00

  Yes.

• 26:57Speaker 01

  They're paying out of pocket. They're not in our system.

• 27:00Speaker 00

  Yeah.

• 27:00Speaker 01

  There could be a domestic option like that. It exists today, but it just make it easier, lower friction.

• 27:05Speaker 00

  It's very hard to do that today. So maybe that's one.

• 27:09Speaker 01

  Okay. So we're going to jump around across some of the predictions just to hit ones that are more relevant. If consumers are defecting.

• 27:17Speaker 00

  Sure.

• 27:18Speaker 01

  Coordinating more of their care.

• 27:19Speaker 00

  Yeah.

• 27:20Speaker 01

  And spending more out of pocket. One prediction is that screening diagnostics and at-home sample collection becomes the hot area.

• 27:28Speaker 00

  Yeah.

• 27:28Speaker 01

  So, so lay out the case there. So Lil' Jon is doing colon cancer screening commercials. People are shipping their poop around the country like just crazy.

• 27:37Speaker 00

  Not even for healthcare.

• 27:38Speaker 01

  Not even relevant. They're just doing it, you know, check your, wash your hands after you check the mail. Lay out that. Why do you think that's going to happen?

• 27:44Speaker 00

  Well, I mean, to be clear, I don't think it's because the uninsured thing happened.

• 27:48Speaker 01

  Sure.

• 27:48Speaker 00

  But I think that diagnostics, I feel like such an interesting area that. It's like very under invested in. Yeah. You know, I think maybe one thing to tie to the uninsured, maybe not uninsured, but cash pay rather. Is that I think this is one of the areas that a lot of people, when you talk to doctors and you talk to patients, this is one thing that I feel like there is a somewhat irreconcilable difference here that they just can't think about. Like the people want to be monitored in some capacity. And a lot of the doctors will be like, well, you can be monitored, but there's not much we can do. Even if you get monitored, right? Like it's not like your care pathway is going to change during that. But a lot of people just like want to be monitored, right?

• 28:29Speaker 00

  Cause they feel like someone is looking out for them and they're being considered at all points and blah, blah, blah. So I think that people want that and especially in the cash pay. And you see this with the longevity medicine and all this kind of stuff. Like a big component of what they want is just like being monitored, right? Even if it says nothing, it's just at least we checked, you know? So I do think that the appetite for that is really high. I think as you move to more of these AI native care models, that becomes a really core part, right? The shift from reactive care to proactive care really has to come from what is the data source that's going to tell you? That something has to be done, right? And I think that is going to come from some form of screening diagnostics, et cetera.

• 29:10Speaker 00

  You know, we talked a little bit about the AI, about AI prescribing, for example. I think the next level above that, which will be interesting is like AI ordering things like labs or, you know, follow ups that you might need pre the doctor actually needing to look at it, right? And I think that is going to be sort of a part of this. But in general, like I think diagnostics also are seeing a more interesting go to market strategy too. Which is, hey, we basically see a big cash pay market that was just wanting to be monitored. While in the meantime, maybe we go through a more legit, you know, lab developed test or FDA approval route. But there's this appetite here for these like new tests to just be monitored on different metrics that maybe are not typically monitored.

• 29:55Speaker 00

  And they see this appetite from people to do that, like especially for example, if you have, you know, some family risk of something, right? But you don't quite fit really neatly into guidelines around like that you need to be prescribed this thing. People are gonna find alternative routes to doing that and they have money to do that too. They're gonna pay for it. Coronary, you know, calcium CT scans, like, great example of this, where like, for some reason, it's really hard to get that. And also, there's like, still a huge lag between like, evidence and, sorry, research and then care guidelines, right? So, the lag is like, 10 plus years in a lot of cases, between what's interesting and what actually makes it into, hey, we're doing this for all patients and all this kind of stuff. But people are willing to pay to, to escape that.

• 30:40Speaker 01

  Have you done it?

• 30:41Speaker 00

  The calcium scan? I'm not, dude, but I'm like, you know, if you're a 30-year-old brown person, like, you're suddenly in a risk category that you have to be thinking about this.

• 30:52Speaker 01

  It's, it, I'm a perfect example of what you just described, which is slightly high on the border cholesterol, South Asian males, I have risk factors.

• 31:02Speaker 00

  Canon event.

• 31:02Speaker 01

  Yeah, exactly. And so, my doctor was like, you definitely don't need a calcium CT scan.

• 31:07Speaker 00

  What does he know?

• 31:08Speaker 01

  What do doctors know? Just kidding. But, I did it anyways.

• 31:11Speaker 00

  Cool. What'd you find out?

• 31:13Speaker 01

  It was a zero, which is good. But I wanted to know that. It's good to know.

• 31:16Speaker 00

  Exactly. Like, I, I think the tough thing, I think the thing that we have to figure out as a society a little bit, is that the existing healthcare system really wants to be like, hey, here are, they really wanna create standardized care for people, right? And standardized guidelines to make medicine also good at the median level for everybody, right? But, at the same time, people want more agency in their healthcare, in some capacity, right? They wanna feel, no one wants to be told like, hey, just wait and see. They just don't wanna be told that. And, there are probably a lot more lower-risk things that we can just let people try and do and see.

• 31:56Speaker 00

  Like, I think this is one of the reasons, for example, that protocols are so popular right now, like Huberman protocols and period of T protocols. You know, the core, the core thing of what these protocols are saying is eat well, sleep well, you know, normal advice you get, but...

• 32:10Speaker 01

  It's branded.

• 32:11Speaker 00

  Well, it's branded, but also it gives people like, what seems like a task list that they should actively be doing to like, be good at their health. And, gives them like, supplements to feel like they're doing something.

• 32:24Speaker 01

  Yeah.

• 32:24Speaker 00

  And, whether or not they're doing it is sort of irrelevant, but the feeling of having agency in those situations, I think is actually the important part. So, it's the same with the testing. People just wanna feel like they're in control a little bit and... You know, I think there's some tension here about, okay, there's clearly a line of where patients are just like yoloing until screening tests and diagnostics that then end up with like more pressure on the healthcare system. Like you find incidentalomas in your MRI. Now someone else got to deal with it, all this kind of stuff. But I think people want more agency and getting a test done where you're like, I just don't feel good about what my care plan is today. I'd just like to see and test. It's just for better or worse, just like it's going to be a part of healthcare going forward.

• 33:05Speaker 01

  I think that's right. And I think that creates another debate, which is what do regulators allow these tests and AI applications to say?

• 33:14Speaker 00

  Yeah.

• 33:14Speaker 01

  So I think a lot of these things, you know, the medical establishment will say, well, it's not really going to tell you anything that actionable or that interesting.

• 33:21Speaker 00

  Yeah.

• 33:21Speaker 01

  But these things start on the fringe. My take is that I think it's a good thing. They start on the fringe and then they get more mainstream. I think the reality is that the, the healthcare system that we have today in the US is drastically supply constrained.

• 33:34Speaker 00

  Sure.

• 33:35Speaker 01

  So 23 million Americans work in healthcare.

• 33:38Speaker 00

  Yeah.

• 33:38Speaker 01

  Yet we've got long wait times. You know, you've heard all the statistics.

• 33:43Speaker 00

  Of course.

• 33:43Speaker 01

  Hundred million people plus don't have access to a primary care doc, 40 day plus wait times to see a doc if you can, et cetera, et cetera. And so all that friction is frustrating. And the demand exhaust shoots off somewhere.

• 34:00Speaker 00

  Sure.

• 34:00Speaker 01

  And it's shooting off to all these places.

• 34:02Speaker 00

  Yeah.

• 34:02Speaker 01

  And to your point, people want agency. So that agency is going to go somewhere. And, you know, where is it shooting off? It shoots off at LLMs. So, you know, you saw the OpenAI report, 230 million people around the world using ChatGPT for health-related questions each week.

• 34:20Speaker 00

  Yeah.

• 34:21Speaker 01

  Forty million a day. It's crazy. It's crazy. It's replaced, you know, Dr. Google and many other things.

• 34:26Speaker 00

  Yeah.

• 34:27Speaker 01

  You know, the proactive health tools are being adopted by a bunch of people. The health memberships, the wearables like Aura and Woo, you know, name your thing. And that makes sense, right? People want to do stuff with that, but there's still regulatory friction that I find interesting. And I'm kind of curious to see how it plays out this year, which is at least as of a few weeks ago. And prior to that, there were two buckets for a device. FDA either said it's a wellness product and it can't make any medical claims at all. Or it's a medical device and you can make all the claims you want, but you've got to go through a long regulatory approval process. Yep, yep. That, as we know, largely favors the incumbents, the big med tech companies, really hard for startups.

• 35:11Speaker 01

  So there's not that many on a relative basis, devices that have emerged relative to, I think, what could have been possible. Yeah. You know, I'm touching my Aura ring as an example. So, you know, so Tom at Aura, we're not investors there, but I think he wrote this amazing op ed in the Wall Street Journal. They basically said, there should be a third category. And that third category is digital health screeners, which is there's something in between. That's not necessarily going to give you direct medical diagnosis, but will show you a couple of things that you probably want to know about your body and you might want to talk to your doctor about. So, you know, the examples that he gave in the article that I thought were good were maybe there's a couple of early indicators of high blood pressure

• 35:52Speaker 01

  that it can infer and tell you to say, hey, you might want to talk to your doc about hypertension. And I think, I can't remember the last statistic, but 40% plus of adults are diagnosed with hypertension or something crazy like that. So it's a real chronic condition that's challenging. The other one that they give in the article is, you know, hey, there's some sleep irregularities that are probably predictive of sleep apnea. Talk to your doctor. Yeah, totally. Right? Like, we should just let that go. And I think that's the, there's obviously something in the middle where you could get all this data and then just drop it into your LLM. People are doing it anyways. I drop all my medical data into council and, you know, pick your one. And, you know, that's where it's going. FDA.

• 36:36Speaker 01

  Said some things that suggested that they're gonna

• 36:39Speaker 00

  They give the hint, hint, wink, wink.

• 36:40Speaker 01

  Yeah, they're gonna, they're gonna roll back some of these things on wearables, but like, wearable is just the start, right? Now you get into AI doctor applications and what can they say, what can they do? So what do you think of that?

• 36:50Speaker 00

  I mean, again, I think the question is, how mu- as a society, how much risk do you think that patients should be allowed to take on themselves?

• 36:59Speaker 01

  Yeah.

• 36:59Speaker 00

  Right? Like, the AI prescribing thing maybe is a good example here, right? And we'll come back to the diagnostics for a sec, but do you think that a person should be able to say, hey, I want to be able to pay $4 to see the AI doctor who's gonna auto prescribe me via these common meds? It might get it wrong sometimes, and if it does, then it'll harm me. Or I can choose to pay a higher amount and see a doctor that maybe has more sort of like higher accuracy or whatever it is, and lower chance of me doing risk of having an adverse event or whatever, like getting prescribed the wrong thing, whoever. Should I be able to make, should I be allowed as a person to make that choice? That like, I want the AI doc that maybe gets it wrong more often, but is cheaper or not? Probably

• 37:43Speaker 00

  same thing for screening diagnostic wearables, right? Where it's like, hey, here's the thing that might find some interesting stuff in your data, but also it's gonna have a false positive rate of this much, right? And you can choose that. Now, I will say the issue here a little bit is that the burden of the false positive rate then falls on the doctor you go and see, or the health system, or the emergency room. So I think that is like a real consideration we have to think about is like, when people have these devices at scale, suddenly, the risk of when false positive rates happen, like, it's gonna be millions of people, right? That's no joke, right? But also, at the same time, I think we're missing a lot of really interesting data that we should be doing more things with. For example,

• 38:29Speaker 00

  I think, you know, I've been talking to a bunch of people that have been wearing CGMs for a while, and a lot of them, I think, for example, have different pathologies of what traditionally looks like diabetes. Like, for example, I think diabetes is this like broad category, but there's probably multiple underlying things that are actually happening that are actually different forms of diabetes, for example. Probably same thing with like sleep, insomnia, all this kind of stuff. There's probably underlying multiple pathologies, but it's hard to tell that unless you have a more massive stream of data that is coming that can help you tell like how that's changing and how that's changing from a healthy baseline, which I think is really important, right? I am wearing the oral ring today as a healthy

• 39:10Speaker 00

  person. As I develop a disease, it's going to catch things that change from my healthy baseline to like being a sicker person. And those changes in how that naturally progresses, like natural history study, basically, is really important. And I think we probably can do that for more diseases if we had more people wearing this kind of stuff. So...

• 39:31Speaker 01

  This is the real world data dream.

• 39:32Speaker 00

  It is, really.

• 39:33Speaker 01

  This is what we all wanted.

• 39:34Speaker 00

  Yeah. And I think, and I think the problem is real world data has always been focused a little bit more on like pharma use cases. I think there are a lot of people that are also just like, I kind of want to know if there's other people like me who have this sort of weird sleep pattern.

• 39:47Speaker 01

  Yes.

• 39:47Speaker 00

  And what is that, what are they doing? What does that mean? You know? That's, I think, a really open, unexplored space that people have not quite, you know, I think if anyone is listening to this, I think building a patient-first biobank on these concepts, I think, is really interesting. People really do want to know how people that look like them or have biomarkers that look like them deal with that or operate in the world. What does their care journey look like, even if you de-identify it or all this kind of stuff? It's useful

• 40:13Speaker 01

  Yeah.

• 40:14Speaker 00

  to know, hey, this person who had this weird sleep pattern took this magnesium dosage and it actually seemed to work for them. And they actually, you know, when we sub-cohort the populations, they look very similar to you. So maybe you should try it, right?

• 40:27Speaker 01

  Yeah.

• 40:27Speaker 00

  That's very unexplored. And I think wearables and all this kind of stuff is a way to do that. But we can only do that if there is some, you know, way to capture that data in like a like structured way, basically, right? And you need a middle path to do that.

• 40:41Speaker 01

  So that's a good transition to talk about. You had three or so predictions around healthcare AI. And your first one was around... You know, state governments clashing with the federal government on key regulations. Talked about it on across a few dimensions, but let's zoom in on AI. So state governments will clash with the federal government on public health guidelines, vaccine recommendations, AI regulation, insurance law nuances.

• 41:06Speaker 00

  All of it.

• 41:06Speaker 01

  Yeah, let's talk about that. So on AI specifically, I think this is interesting. Last year, we had Illinois and Nevada and a couple of other states either ban or restrict AI therapy chatbot usage. Basically, last week, so since you wrote your piece, we literally had Utah saying, doing the pilot around AI being allowed to prescribe medications. It's very narrow on 190 low-risk medications, your asthma inhaler, you know, pick, you know, things like that, low-risk stuff to start.

• 41:39Speaker 00

  Yeah.

• 41:39Speaker 01

  But can expand. And then President Trump signed an executive order in December saying that effectively said, hey, we're going to do a national framework and we'll make it easy for folks to follow. It sounds like you think it's going to be more chaotic in 2026.

• 41:54Speaker 00

  Definitely.

• 41:54Speaker 01

  Say more.

• 41:56Speaker 00

  I mean, I think it's, I mean, I think there's a couple of things, right? One part is there is definitely an anti-AI sort of movement that is happening in the US, which is sort of expected and natural. And people are worried about job loss and they're worried about how decisions are being made that affect their lives because like maybe there's an AI on the other end that is choosing things that are, you know, anti-helping them, right? So I understand like where that's coming from and that anti-AI movement will inevitably impact policy. And depending on which state you're in, you are going to have a regulator in that state side with one side or the other, right?

• 42:39Speaker 00

  Maybe like a analog here is actually like Waymos, right? Waymos are in a few states. They started in California. They are super. Like, I love riding into Waymo every time I come here.

• 42:50Speaker 01

  Yeah.

• 42:50Speaker 00

  States have very different opinions on whether they should allow Waymos into their own state, right? Whether it's they care about how much they have to prove safety-wise before they roll out, or they, you know, they know there's gonna be widespread job loss when they come in. And I think AI for other things is just gonna follow the same trend, right? And so I think the issue is that, like, states don't quite know what to do. Like, I think we can all acknowledge that there's a lot of, like, also bad AI use cases that we need to watch out for, using deep fakes and weird ways and a lot of this kind of stuff, right? So, as a whole, I think people are trying to figure out, how do we regulate the downside risk of AI,

• 43:31Speaker 00

  while also enabling the, like, upside potential that we can see, right? And maybe it's actually not a bad thing that we're running a bunch of state-by-state experiments to see, like, what works and what doesn't, and then create a more national framework to do this. The downside, though, is then you have to, you know, healthcare's always been really annoying about having, you know, different compliance rules for every state, which means your product looks very different, and the cost to go into a new state is very different. That's gonna be annoying, but actually, maybe we should be running different experiments here. And each state is gonna, you know, it's gonna look different depending on their own healthcare needs as a state, right? If you have a really large rural population, for example, that really struggles to get access to care,

• 44:14Speaker 00

  you are probably gonna lean more heavily into, hey, we need to get, these people don't have a PCP, we need to get them something, right? If you have a very competitive provider network, maybe that's actually not the case, and care accessibility is fine and all that. So, I think that'll, I think, it just really, I think that states are trying to figure out, like, how do we protect the downsides while getting the upsides? But they just don't, they all have a different opinion of what that means. Like, some states, for example, you know, they really don't want insurance companies to use AI to deny claims, right? They're like, they think that's, like, really bad, blah, blah, blah.

• 44:46Speaker 01

  They'd rather have humans deny claims.

• 44:48Speaker 00

  Yeah, yeah. Which, which also, at the same time, I'm also like, how are we even gonna monitor? If a human is using ChatGPT to read the claim and then deny it, is it really any different?

• 44:56Speaker 01

  Yeah, sure.

• 44:57Speaker 00

  Not too clear, but, I don't know, we'll see. Be some fun, fun state experiments.

• 45:01Speaker 01

  Yeah, I think that's right. I think, from a competitiveness standpoint, and from getting all the innovative ideas out there, which ultimately benefits the consumer, I think you've gotta have a national framework.

• 45:13Speaker 00

  Sure.

• 45:13Speaker 01

  Because... If you have a lot of regulatory complexity with different rules in every states, it favors the incumbents who have the armies of legal teams that can interpret all those things and operationalize and scale in that way. You want to level the playing field for big tech and little tech. On the other hand, you want the experimentation. I think when the technology is moving so fast, you want regulation to catch up, but you really don't know what the right answer is. And so it's instructive to have different states experiment for their unique population mix and rural to urban mix, as you described. And so I think the question for me is, do we have the right data infrastructure to learn from all that stuff?

• 45:58Speaker 00

  Sure, that's true.

• 45:59Speaker 01

  The prescription example is an interesting one. Okay, great. You can refill a prescription for $4 instead of $150. Let's see if that works and let's see the upsides and downsides of it. We're going to learn a lot from that state pilot. But that's just one example. We want 50 different examples to play out. And that's the thing that I worry about.

• 46:18Speaker 00

  Yeah, I mean, you know.

• 46:21Speaker 01

  If we wait just for national, basically.

• 46:23Speaker 00

  Yeah, I mean, there's an argument to be made also that I thought, actually, that I think Jonathan Slotkin wrote like a great op-ed about Waymos seem to have proven that they're so good that actually it would be unethical to not rule it out everywhere.

• 46:37Speaker 01

  So good.

• 46:38Speaker 00

  And I think if we can do something around in the lines of, hey, this pilot or this thing looks so good, we really just got to boost it everywhere. I think that can actually be maybe a different way the federal government thinks about things, rather than be like, hey, we're going to set blanket rules. It can be like, all these places should test their own things out. If something looks like it's working, then we make that the rule for everyone else. And then like, speedrun, getting people, getting that, whatever, getting those features or programs out to everybody. Rather than be like, hey, we need to create a, yes, it's working, no, it's working, rules set for every state. Just be like, go run your own pilots and tests and then let's get it up.

• 47:19Speaker 01

  The New York Times article around Waymo is a perfect example. And actually, ironically, it pointed to healthcare and life sciences as an industry that already has this framework, which is if you're running a clinical trial.

• 47:31Speaker 00

  And it looks great.

• 47:32Speaker 01

  And the evidence is as clear as day.

• 47:34Speaker 00

  You stop the trial.

• 47:35Speaker 01

  At some point, it becomes unethical to continue the trial because you're giving the placebo to the control arm and it's causing harm.

• 47:42Speaker 00

  You know it's harming.

• 47:43Speaker 01

  And you know it's harming them. And so.

• 47:44Speaker 01

  What is the framework like that here? I think this is gonna be, this is gonna be one to watch.

• 47:48Speaker 00

  Yeah.

• 47:49Speaker 01

  That relates to IP.

• 47:51Speaker 00

  Sure.

• 47:51Speaker 01

  And all the IP debates around healthcare AI.

• 47:55Speaker 00

  Yeah, yeah.

• 47:56Speaker 01

  So you said intellectual property lines will be drawn in healthcare AI with lucrative copyright and licensing deals.

• 48:02Speaker 00

  Yeah.

• 48:02Speaker 01

  This photo, which will put it up for the people out there with Big Bird strangling you.

• 48:06Speaker 00

  Sometimes my wife walks in on me doing my work and in this case, she's seeing me like output an image of Elmo choking me out.

• 48:14Speaker 01

  Yeah.

• 48:15Speaker 00

  This like really was putting food on the table?

• 48:17Speaker 01

  Yeah, exactly. She's wondering if you have a real job. Yeah, yeah. So, so, I mean, but it's crazy. So, so lay that out, you know, lay out that case for AI overall.

• 48:25Speaker 00

  Sure.

• 48:25Speaker 01

  You know, all the drama deals and litigations that happened last year. And then what does it look like in healthcare specifically?

• 48:32Speaker 00

  Yeah, I mean, on the, in the foundation model side, you know, the big issue has always been like, what does copyright look like? In an era where, you know, the AI service regurgitating or spitting out things or like using IP in ways it was never supposed to be. It's like Elmo choking me out, right?

• 48:48Speaker 01

  Yeah.

• 48:48Speaker 00

  And now there's a bunch of lawsuits slash partnerships that have been happening where different foundation models now are allowed to use the IP from different companies. So I think Disney invested in OpenAI, right? And now presumably can use their IP within it. So, you know, you clearly see these lines being drawn and Anthropic had a huge case against people who have written a bunch of books and all this kind of stuff. So that's being figured out, right? Healthcare has so many copyrighted things. Disease scales, for example, CPT codes, like so many of these copyrighted, they probably has the most, you know, behind a paywall expensive PDFs that exist of any industry somehow.

• 49:27Speaker 01

  Yeah.

• 49:27Speaker 00

  But they're.

• 49:28Speaker 01

  Are we the market leader in paywalls?

• 49:29Speaker 00

  We must.

• 49:30Speaker 01

  That's really sad.

• 49:30Speaker 00

  We must be.

• 49:31Speaker 01

  Okay, fair.

• 49:32Speaker 00

  So if you want to use any of those things, you gotta pay a fee, you gotta pay the piper, right? As long as we are in a system where you have to use those standards or whatever, it, it behooves a lot of these, a lot of the healthcare AI applications to create licensing partnerships with these people who own the IP, right? So that'll probably happen realistically.

• 49:53Speaker 01

  Yeah.

• 49:54Speaker 00

  I think maybe a more interesting one, and I sort of posted this online the other day and kind of got roasted, but I think it's an interesting thought experiment is, I think, protocols are IP, right? I think that the Peter Attia longevity protocol is IP.

• 50:11Speaker 00

  And I think one question has always been like, okay, if you are a Peter Attia, right? By the way, I don't know Peter Attia, but hey, man, if you're listening, let me know. Let me know what you think.

• 50:21Speaker 01

  I would buy.

• 50:21Speaker 00

  Help me not die.

• 50:22Speaker 01

  I would buy the Peter Attia protocol.

• 50:24Speaker 00

  Yeah.

• 50:24Speaker 01

  Cause I can't, you know, his, to be on his client list, he charges a really high fee. But make that available.

• 50:31Speaker 00

  Yeah. Like also, if there's a Peter Attia trained agent that is implementing the protocols at the, you know, patient intake level, at the like dose escalation level, whatever, then you can potentially just see a regular doctor that has a wraparound of the Peter Attia protocols that, you know, helps you do all the things that you normally would at his clinic, essentially, right? And you pay maybe a lower price than the normal clinic, right? But I think that becomes an interesting thing of, hey, I want to create my own protocols that I think are maybe slightly outside evidence-based medicine guidelines and then gets implemented at other clinics, right? But a lot of those clinics might implement

• 51:11Speaker 00

  it in the form of AI agents or other ways to actually execute that. So that's like a slightly different area that I actually think is maybe more interesting. But at the baseline, you're already seeing like open evidence partnering with like JAMA or I think it's New England Journal of Medicine, just to be able to like pipe that data in. So all the paywalls will probably end up finding their own specific healthcare application and be like, hey, this is the one we're licensing it to. Whether it's exclusive or not, it's sort of TBD, but at least they could probably have those agreements.

• 51:41Speaker 01

  What do you think are the biggest data sets in healthcare that are still untapped? Cause you know, there's builders listening that are just trying to figure out what's next. So AMA CPT codes, Milliman clinical groupers, health system, clinical EHR data, PBM data, famous doctors with their own protocols.

• 51:59Speaker 00

  But you know, the honest answer is I think a lot of those data sets are like not great data sets.

• 52:04Speaker 01

  Yeah.

• 52:04Speaker 00

  They're, they were created and built and used for a very different purpose than probably want to use it today, right? Like today, we use so many of those data sets as proxies to figure out something other ground truth, right? Like for example, we will use prescription claims data sets to figure out if a person has diabetes rather than just seeing like, hey, let's connect your CGM and just see do they have diabetes or not, right? I think a lot of the existing data sets in healthcare are like quite bad, actually. And I actually think the more untapped data sets are these net new data sets that are going to be created either from screening, wearables, etc. But also things like scribes, for example, right? Scribes capture raw audio text data from the encounter.

• 52:48Speaker 00

  That is like totally net new data set that is really interesting to use, that you can do with, you know, lots of things. Like, for example, you know, for anyone listening, one thing that I think would be really interesting is net new medical malpractice carriers. Like, why is there not now a metro mile equivalent but for med mal, right? You put a thing in, if you are, you know, we sort of listen to how you practice medicine. If you tend to do it within like appropriate guidelines and all this kind of stuff, we will actually give you a better rate, right? I think a lot of these net new data sets will actually allow us to do other interesting downstream things, too. But I think the old data sets are just like, they're just kind of jank and used for things that are like, they're not supposed to be used for.

• 53:31Speaker 00

  We gotta stop using fucking claims data sets for real world evidence. Like, it's just, it's just that wasn't meant for that, you know?

• 53:37Speaker 01

  Yeah, I mean, especially like PHRs are back and then OpenAI bought a PHR.

• 53:42Speaker 00

  Yeah.

• 53:43Speaker 01

  And then maybe PHRs are not back anymore, maybe the LLMs are gonna do it. But like, personal health, people are uploading a lot more, I'm uploading a lot more of my stuff.

• 53:51Speaker 00

  This is a great example, right? Like, PHRs now, obviously for personal health records, have been one of those ideas that everyone has pitched every year and then, but you know at some point it'll happen, right? Like, it's just kind of unclear when, and the missing piece has always been interpretability, right? It's, hey, you're giving me all this data, but I don't really know what to do with it. I gotta go back to the doctor anyway to interpret it, not that useful, right? Now with AI tools, you have more interpretability that unlocks a whole new case. And more importantly is that it gives patients a reason to now dump more data into these things, right? Before it was like, okay, if I dump more data into the personal health record, my doctor doesn't want to see all that. It's a lot of noise. I don't know what to do with that. There's nothing more to do, right?

• 54:35Speaker 00

  But if now suddenly I'm like, oh, I'm actually getting more interesting answers the more data I put into it, then suddenly you have patients wanting to generate more of their own data to put into this, right? That creates totally net new data sets. You know, patients might actually also like, you came from the clinical trial world, for example, you know, one part of clinical trials is patient reported outcomes.

• 54:57Speaker 01

  Totally.

• 54:57Speaker 00

  Those like diaries that patients have to fill. No one's filling that out, right? It's a terrible completion rate. But suddenly, if you're like, hey, you'll actually learn more by chatting with this thing that we have that will tell you more answers, maybe about the drug or anything like that. There's now an incentive to actually like chat with this and give it more information. And that's like totally net new data, which I think is also probably closer to ground truth of how people are actually feeling about their health than that kind of stuff.

• 55:25Speaker 01

  That extends to anti-AI populism.

• 55:29Speaker 00

  Yeah.

• 55:29Speaker 01

  So, so lay that one out. You know, we basically, we effectively just spoke about the bull case for AI bridging the supply gap. We don't have enough docs, not enough physicians, AI is going to bridge the gap. Explain the populist revolt.

• 55:43Speaker 00

  I think it's a few things, right? Like one, I think, look, the reality is healthcare is a jobs program in the US.

• 55:51Speaker 01

  Yeah.

• 55:51Speaker 00

  Right?

• 55:52Speaker 01

  Twenty-three million.

• 55:53Speaker 00

  It is the number one employer in the US, especially, or I would say these, you know, kind of administrative jobs in particular. Like, the number one job category is still patient care, right? Like, it's patient-facing caregivers and all this kind of, you know, LCSWs, all this kind of stuff. But there's a big layer of administrative people who are very comfortable in their jobs, do not want, can, their jobs can definitely be automated, and do not want to see that happen. So I do think one thing you'll see is just people afraid of job loss, as with any other new technology as it comes out, and wants to fight back against that. The second thing that I think you'll see happen is there's going to be a weird fight

• 56:34Speaker 00

  that happens between what a doctor thinks they should be doing and when they think that the AI should be telling them what to do, right? Because this is going to be like a strange thing where either hospital admin or payers or something are going to start saying, hey, you've got to consult the AI. Yeah. For this XYZ, or we're mandating scribes and the scribe is not that good. And then suddenly they're like having to repeat a lot of stuff. Like, I do think the implementation of this kind of stuff is going to be kind of clunky. And because of that, people are going to have bad experiences with it. And when they have bad experiences, they're going to feel a little bit like they're being encroached on, right? So I think those are some of the areas that'll happen. And then I also think realistically, there's going to be a big, some big AI mistake that happens in some capacity.

• 57:19Speaker 00

  You're kind of already seeing that with ChatGPT with, you know, the kids who are committing suicide because the bot is like convincing them to do stuff. And people are already having some like, hey, we need guardrails here, right? There's some backlash on what we think should, how it should be allowed to interact with kids and all that. And I think you'll see like a big healthcare issue that happens where someone's really misdiagnosed really publicly or something like that happens. And then people are going to say, hey, we need more guardrails here, or we need more observability, or we need something that tells us that, hey, this is, you know, this is a one-off, or we won't let it do really high-risk things or something. I think people will push to regulate those things. Whether it's right or wrong, I don't know, but I just think that'll happen.

• 58:02Speaker 00

  And by the way, you see, already saw this with the internet when it happened, right? Ryan Hightower's are a great example of this, right? Where a, I believe it was a teenager, got access to controlled substances through a internet-enabled service of some kind. And then they put rules, and I overdosed, I believe, and they put rules around like what you could do and what you couldn't. And then those rules just stayed for a really long time. It's hard to roll back rules like that once they get implemented. And if the case is high-profile enough. Yeah. So the question is. This will definitely happen. What is our response going to be as a country?

• 58:36Speaker 01

  Okay, so let's just go through the three major populist arguments. So you touched on them. So the first is AI will destroy all the healthcare jobs. Okay. The second one is AI makes mistakes and patients will die.

• 58:51Speaker 00

  Yeah.

• 58:52Speaker 01

  And then the third is that AI takes away patient choice and autonomy and creates confusion for the physician, right? Because it's that, can the patient choose or is the doctor required to get the second opinion anytime? So let's just go through each in turn. The AI describes, excuse me, the AI will destroy the healthcare jobs.

• 59:12Speaker 00

  Yeah.

• 59:13Speaker 01

  Go against that one.

• 59:15Speaker 00

  I mean, as in you want me to say like why we shouldn't?

• 59:17Speaker 01

  Yeah, like argue against the populist case.

• 59:20Speaker 00

  I mean, the argument is, I mean, that one is easy, right? Which is like, everyone always complains about the administrative cost and bloat of healthcare. So we should definitely want to decrease that. And not even just from a cost perspective, but from like an experience perspective for everyone. No one likes dealing with the administrative part of healthcare. So it seems very obvious that we should try and remove that. And actually, maybe that will push more of those people into jobs and roles in the healthcare system that don't exist, but actually would be really useful, like proactively taking care of people or checking in on them or doing more of the community related stuff for patients in the communities of the providers themselves. So those are like bad, those are like bad tasks and jobs. And I think are just like, we shouldn't have them.

• 1:00:04Speaker 00

  So I don't, I think that one is like the easiest to be like, listen, that one's arguing for admin, man.

• 1:00:10Speaker 01

  That one's easier. By the way, that's always been the anti-technology argument. You know, it's automobiles, we're taking jobs from horse trainers. ATMs were taking jobs from bank tellers. And, you know, in a lot of those cases, not all, but in a lot of those cases, we have more of that prior job, but just doing something, we have more bank tellers today as an example, right? So, so, so I think that's one big one. The other one is just that it's super supply constraint. So I think in some other markets, there probably will be some more drastic jobs. This location, but I think in healthcare, it's just a simple supply, demand mismatch. Right. There's just, we're employing more than any other sector. And yet we still have record shortages.

• 1:00:52Speaker 00

  Yeah.

• 1:00:53Speaker 01

  And so, and it's not getting any better.

• 1:00:55Speaker 00

  Yeah, yeah, yeah.

• 1:00:56Speaker 01

  So.

• 1:00:56Speaker 00

  I mean, there's an unlimited demand for healthcare.

• 1:00:58Speaker 01

  Unlimited demand.

• 1:00:59Speaker 00

  So if you enable people to get more services, they're going to get it. And that's also probably not a bad thing, right?

• 1:01:05Speaker 01

  Yeah.

• 1:01:05Speaker 00

  People want to engage with their health, like we should actually probably let them if they really want to.

• 1:01:09Speaker 01

  Okay, go through the second. So AI makes mistakes and patients will die.

• 1:01:12Speaker 00

  So I think the case here is more around, like, we have to think about type one and type two errors a little bit. Right. Where it's, okay, it's obvious that AI is going to make a mistake at some point and something bad is going to happen. But how many net people did it help? Right? And you have to weigh the costs between those things, like for every, and you even see this just like anecdotally on the internet. For every person that it's probably going to make a mistake for, it's also has one person that was like, I, you know, was never diagnosed and I found out I had this rare disease, thanks to dumping all my files into Gemini. And now I learned that like, I can be saved, you know, some random case like that.

• 1:01:51Speaker 00

  But also just like the median level of care, if it gets better, then it's a little bit of just risk reward. For every mistake that happens, how much benefit is going to happen? And I think the answer probably is it's in the median AI implementation at some point is going to like raise the bar for everybody, even if it means a few edge case mistakes. And I think you have to be comfortable with that if you want to roll this out at scale.

• 1:02:19Speaker 01

  And humans make mistakes too.

• 1:02:20Speaker 00

  Humans make mistakes too. Like, again, the doctronic one, I think is just like an interesting case study here where it's like, you actually, what you would want to do is compare maybe like the doctronic autonomous AI to you're filling out a form from asynchronous erectile dysfunction company. Like they probably make mistakes too on the other end.

• 1:02:39Speaker 01

  Yeah.

• 1:02:39Speaker 00

  Right. But if it's the same level of mistakes, then we should maybe be okay with it if the cost is cheaper. But also maybe it's actually better.

• 1:02:46Speaker 01

  Yeah.

• 1:02:46Speaker 00

  Right? So even if it makes, even if it makes some catastrophic errors every so often.

• 1:02:51Speaker 01

  There's so many counter arguments here, but the one that interesting, which you already alluded to is that AI creates an audit trail. Cause everything is documented.

• 1:03:00Speaker 00

  Yeah.

• 1:03:00Speaker 01

  And so, you know, people are really concerned about the black box of AI. But you can see the decisions, at least now, in this way as a sort of loop. And so that also creates an interesting data, like you have data provenance. You can look back and you'd see why a decision was made.

• 1:03:15Speaker 00

  Like where in the reasoning did it mess up?

• 1:03:17Speaker 01

  Right.

• 1:03:17Speaker 00

  Fix that.

• 1:03:18Speaker 01

  Right.

• 1:03:18Speaker 00

  And not have that happen going forward.

• 1:03:21Speaker 01

  Right.

• 1:03:21Speaker 00

  Imagine trying to deploy that fix at scale with all the human doctors.

• 1:03:25Speaker 01

  Can't do it.

• 1:03:25Speaker 00

  Right. It's really hard. That's actually why we have evidence-based guidelines.

• 1:03:29Speaker 01

  Yeah.

• 1:03:29Speaker 00

  Right? Like you're trying to prevent a lot of those cases. And in order to do that, you have to deploy care guidelines. But if you could make a change to the, an AI model at scale, actually maybe that's easier.

• 1:03:40Speaker 01

  The third is around AI takes away patient choice. So if your insurance company uses AI for prior authorizations, you're not opting into that.

• 1:03:50Speaker 00

  Yeah.

• 1:03:50Speaker 01

  You know, it can be dehumanizing. You know, now I'm talking to an AI chatbot, but I really want to talk to a human.

• 1:03:57Speaker 00

  Yeah.

• 1:03:58Speaker 01

  It's related to the physician piece where now you're second guessing a doc every single time.

• 1:04:03Speaker 00

  Yeah.

• 1:04:03Speaker 01

  What do you make of this?

• 1:04:05Speaker 00

  This one is a little harder, but again, I do think this process is already happening. It's just with a human in it, right?

• 1:04:12Speaker 01

  Yeah.

• 1:04:12Speaker 00

  And because of that, it can be really, there's a lot of variability in who you talk to on the other side of things. Right? You'll see lots of patients, for example, that, that know which person you want to hit for customer service to get the right answer and blah, blah, blah.

• 1:04:26Speaker 01

  Yeah.

• 1:04:27Speaker 00

  And you know, there's a lot of variability in that. So maybe this provides more standardization at least, like you understand the rules of the game. And you have to, you know, basically that's how you play it. And it's more understandable and you get answers faster at the very least, even if it's not the answer you want. At least it's quick. But also at the same time, again, it's just, you always have to compare it against the human being, I think. And the core problem, I think there, especially with like payers, prior auth, all that kind of stuff, has nothing to do with technology. Right? It's really just a, there's an incentive misalignment between the payer provider and insurance company in a lot of cases. The AI is probably just like encoding that, but it's not that different than deploying a call center agent with rules. Who needs to follow them? Right?

• 1:05:12Speaker 00

  So again, it's the same as the other ones where it's like compared to the human version of that, is that better or worse? If you can get answers faster, I would argue it's better.

• 1:05:21Speaker 01

  Right?

• 1:05:22Speaker 00

  No one wants to be like waiting to hear from the insurance company if the prior auth went through. At least get the decision quickly so you can move on to the next thing at least and argue whatever it is. But just get the decision quickly.

• 1:05:34Speaker 01

  Yeah, I've heard this argument feels like the luxury argument to me.

• 1:05:37Speaker 00

  Yeah.

• 1:05:37Speaker 01

  Where. Sure, if we could have one doctor for every patient and they would get 24/7 attention.

• 1:05:45Speaker 00

  Yeah.

• 1:05:45Speaker 01

  Then sure, maybe AI takes away from that, but that's not the reality. The reality is we've got a labor shortage and we've got long wait times. And so if you've got a AI agent that's 24/7 available, infinitely patient, has all your medical context and getting back to you quickly.

• 1:06:03Speaker 00

  Yeah.

• 1:06:03Speaker 01

  I think people want that.

• 1:06:04Speaker 00

  Definitely.

• 1:06:05Speaker 01

  And I think we create, I think in areas where we can create choice, I think the data, my expectation would be the data would suggest that people want that.

• 1:06:12Speaker 00

  But the bots gotta get better, man. Have you like called an AI bot recently? Like, I mean, some of them are real bad and there's, I'm like pressing zero to call.

• 1:06:21Speaker 01

  Yeah.

• 1:06:21Speaker 00

  So the deployment, I think, actually really matters here. And my worry a little bit is that payers have no incentive to actually make this like a good experience.

• 1:06:29Speaker 01

  Yeah, that's like a version of the Turing test is at what point do you not automatically just say representative?

• 1:06:34Speaker 00

  Yeah. And they're like, I am a representative.

• 1:06:38Speaker 00

  I see that like to not talk to a bot, it's like, sir.

• 1:06:41Speaker 01

  How do you know? How do you know I'm not a representative?

• 1:06:44Speaker 00

  Oh, I'm sorry, I did you.

• 1:06:45Speaker 01

  Yeah, exactly. Okay, so, so we've talked about AI and so, so we think dollars are going to go in different places.

• 1:06:53Speaker 00

  Sure.

• 1:06:54Speaker 01

  They're going to spend it on screening, they're going to spend it on AI applications. Now let's talk about drugs. So you had a prediction in there GLP-1 usage rates will more than double, but they won't work well on mental and behavioral health issues. So set this one up.

• 1:07:06Speaker 00

  Yeah. So the big thing this year is that the pill version of Wegovy is coming out.

• 1:07:11Speaker 01

  Yeah.

• 1:07:12Speaker 00

  So, you know, suddenly, and now also there's a ton of negotiations that have happened, both from the government side to bring these costs down as well as, you know, pharma going direct to consumer, which is a very new thing. And also the PBM rebates, right? Like everything, this is such a competitive drug class.

• 1:07:29Speaker 01

  Yeah.

• 1:07:29Speaker 00

  That the prices are going down, right? And new modalities now are being created like the pill form. And you have these like new stronger doses or different combos like tide and reticute tide and all this kind of stuff. Incredibly competitive drug class, right? So, and it is also, again, like, basically near infinite demand. Like, people, everyone wants to not be obese, right? Near infinite demand here, so it's clear that a lot of people are gonna be taking this drug, right? It's just clearly gonna happen. I think, I forgot, I think maybe last year we were like 10 to 12% if I remember correctly, or so, maybe 15, somewhere like that?

• 1:08:09Speaker 01

  That sounds right.

• 1:08:10Speaker 00

  So, now with this pill coming out and the prices coming down and everything, like, it's gonna, it's gonna go up, for sure. I mean, the percentage of the US population that is obese is like gigantic. So, the number of people who wanna take this is gonna go up. I don't think anyone's gonna, gonna doubt that a lot of people are gonna be on this drug, right? It's just, it's gonna be high. My guess was 30%, just based on where we were at a baseline, but, and it's always nice to put numbers around predictions, so let's see if I'm right about that. The mental behavioral health one is interesting because this is, you know, it's funny, it's like, in this whole vein of people doing self-experimentation, one thing they have been doing is around, let's try Jelpi once for everything, right?

• 1:08:53Speaker 00

  And a very classic area is, oh, it's helped my mental acuity when I like microdose Wegovy in the bathroom, right? So, people have been experimenting on this and, you know, they're like, oh, it brings me so much mental clarity, and lots of theories around how the actual thing that, that these drugs are solving is really a dopamine regulation issue on how you think about food. So, really regulating food addiction, essentially, right? And that can that cross over to other addiction types, right? But a lot of trials in the past have actually, in a similar-ish mechanism of action, have tested some of these areas, like in smoking and alcohol and all this kinda stuff. But like, not fantastic results, actually.

• 1:09:33Speaker 00

  So, maybe, you know, changing the dosages and the formulation and all that kinda stuff does change that. But it doesn't seem, again, this is just a guess, and I'm not a doctor, I'm just like a dude with a newsletter. It doesn't seem like it's going to work that well for addiction. And even, you know, they tested in Alzheimer's, it didn't really work out that well. So, I think they, there's still a lot of room here to like, experiment, but I, my guess is just for mental behavioral health, it's not gonna work that well. One idea I actually heard recently, I- I have quite a few friends slash people who just slide in my Instagram DMs for unclear reasons about my their patient journeys. And whenever I post with GLP-1s, people will tell me like a different GLP-1 story that they have. And a lot of people with like

• 1:10:18Speaker 00

  inflammation related diseases, so think like Crohn's and ulcerative colitis or psoriasis, for example, have found that microdosing the GLP-1 actually seems to be helping them a lot. Like, one person just recently told me they stopped their biologic and the GLP-1 seems to work for them. And that actually might be a different, interesting area that it might work better than we expect. But I don't know, mental behavioral health stuff, I don't think it maybe is going to work as well. But I could be totally wrong about that.

• 1:10:50Speaker 01

  We're gonna learn a lot.

• 1:10:51Speaker 00

  There's some trials also, I think, readouts this year.

• 1:10:53Speaker 01

  It's clear that there's a lot of trials running on a lot of different things. You're the meme of the GLP-1 golden hammer. You know, why does it work on everything I touch? I mean, it's the efficacy is dazzling. It's crazy how many places it's working.

• 1:11:07Speaker 00

  Put in the water supply, man.

• 1:11:08Speaker 01

  It might be like the next statin or the next just put in the water supply kind of thing. So, you know, I know less on that part, but I would very much agree that there's basically five accelerators that are just gonna, it maybe goes past 30%. I mean, we'll see. I mean, the consumer awareness, I think the dazzling efficacy for a lot of conditions has captured the intention of a lot of people. It's in the zeitgeist, it's out there. One you didn't talk about, but I think is important is just the rate, and this is true for GLP-1s, it's true for all new medications, therapeutics, devices, I think, which is just evidence dissemination is also happening faster. Certainly, tools like Open Evidence and ChatGPT, like docs using that means the information gets out to the community, you know, treatment patterns

• 1:11:53Speaker 01

  change more rapidly. And I think there's some data to support that.

• 1:11:55Speaker 00

  Yeah.

• 1:11:56Speaker 01

  But also to consumers, right? Because you're, we're playing around with these tools and they're telling us things. The convenience factor, no question. I think the oral formulation is a big deal. The new channel, relatedly, the new channels, I think, is something that I expect we'll see a lot more of, which is You know, you had the oral formulation of Wegovy on day one of launch effectively, go live on all these digital health channels. So it was on Ro, it was on GoodRx. That one's kind of a newer phenomenon. It used to be that you'd go your mainstream channels that your commercial pharma org has you, you know, you know, your people, you know, your docs, you're going to talk to the docs that are the influencers, the

• 1:12:38Speaker 01

  KOLs. You're going to go talk to the docs where you ran the study and their trial sites.

• 1:12:42Speaker 00

  Now you're talking to TikTok influencers. They're the KOLs.

• 1:12:44Speaker 01

  Now you're talking straight to TikTok, right? It's crazy. So I think that is another channel that is only getting bigger. And then I think the fifth is just around reimbursement and payment. I think to your point, that some of these categories are complex. I think the formulations are changing, or patients are getting more formulation options. And those may have different prices or different, they may distribute through different channels. And that'll have its own, there'll be their own competition that obviously, you know, TrumpRx is going to bring prices down. And you're going to, you're going to just have a lot of, a lot more channels and a lot more options. So I'm excited about that.

• 1:13:21Speaker 00

  Drugs are a consumer product. They always have been. Obesity is just the area which has so much demand. And people understand their own disease pathology so well, that they know how to buy, like what they want, right? Versus it's hard for me to be like, hey, I know what cancer drug I need, or like rheumatoid arthritis or whatever. But it's, hey, here's a pill that actually helps with obesity. I understand that I have obesity. And I, you know, it's the first, I think it's very cool to see a drug company treat itself like a consumer products company. It's very rare.

• 1:13:55Speaker 01

  Yeah. And I think these, I think some of these channels where I think if you've got now, you know, effectively an AI doctor in your pocket, whether it's physician supervised or not, gives you another channel to have conversations and understand what's right for you and what's not. I think a lot more patients are going directly there to their doc and saying, hey, should I be on a GLP-1, right? So there's just a very different, it's a very different level of pull versus like the old school pharma ad that's, ask your doctor about X, and then let me tell you the 15 side effects.

• 1:14:25Speaker 00

  Yeah. And they're like having a grand old time in the field. And they're just like, you might shit yourself to death.

• 1:14:30Speaker 01

  Yeah, exactly. Okay. So that's one drug class that's growing very quickly. There's another. Category of drugs.

• 1:14:38Speaker 00

  Of course.

• 1:14:38Speaker 01

  Other peptides, so not GLP-1s. You have a prediction the FDA will crack down on gray market peptides and create regulations for legit compounding facilities.

• 1:14:48Speaker 00

  Yeah, NASTF and I've been trying to find these compounding, these peptide parties and no one's invited me. I'm a little offended.

• 1:14:53Speaker 01

  Okay, so we're gonna, we'll show a picture of these peptide parties from that one article. I mean, it's crazy what's happening with, right now. So let's set this one up, but you're predicting the FDA cracks down on gray market peptides in 2026. The plot twist is basically, so your prediction, I think, came out at the end of December.

• 1:15:11Speaker 00

  Yeah.

• 1:15:11Speaker 01

  Six or seven days later, RFK Jr. says FDA's war on public health is about to end, including its aggressive suppression of peptides.

• 1:15:20Speaker 00

  Yep.

• 1:15:21Speaker 01

  Okay, so for people that don't know, so peptides are amino acid chains.

• 1:15:25Speaker 00

  Sure.

• 1:15:26Speaker 01

  There are some FDA-approved peptides, GLP-1s are an example, but then there's a whole category of unapproved peptides.

• 1:15:34Speaker 00

  Yes, exactly.

• 1:15:35Speaker 01

  Many of which are coming from China or at compounding pharmacies. Both are unregulated or gray area, you know, areas. And people are trying them. And there's peptide parties, as we've discussed.

• 1:15:47Speaker 00

  Mm-hmm.

• 1:15:47Speaker 01

  They look like raves, but everyone's drinking non-alcoholic beer and soda water, but then injecting themselves with needles. And so it's a-

• 1:15:55Speaker 00

  They're worried about the alcohol, dude.

• 1:15:56Speaker 01

  Right, right, right. Exactly. So, you know, on one hand, maybe we're becoming healthier and then maybe we're trying new things.

• 1:16:02Speaker 00

  Seriously.

• 1:16:03Speaker 01

  So, so yeah, so, so sorry to interrupt you, but lay that out.

• 1:16:05Speaker 00

  So, I mean, it's actually interesting because, you know, you would think it's maybe just like the small biohacker types, but like, I know quite a few people who are older who take it for things like pain. Like BPC, I think 157 is a very common one, that people will use and inject in their joints to help alleviate pain. And I actually think one of the things that shows is for their areas where there's like unmet need, right? There's not really a lot you can do for joint pain or whatever, that people are, because pain is so bad, they are willing to try a lot of things, right? Including these like really experimental drugs. So, I mean, the prediction is not that there, we're not gonna

• 1:16:47Speaker 00

  have more peptides in the US. It is that the current way in which we procure peptides, if you want to do them- Is through very shady sources, like to the date, people are either buying it online in these sites that look like, you know, infomercials from the 90s. Or they're going to their doctor and they're like, hey, where can I get this? And the doctor has some relationship with trusted compounding pharmacies that they have seen or whatever. And it's just like all over the place, right? There's not really any regulations around how we procure source, you know, measure the, for example, like the dosages and all this kind of stuff, just like total Wild West. So my, my theory is that there's, you know, what I thought was going to happen is there's going to be some,

• 1:17:32Speaker 00

  again, big news story or whatever of a bad batch that like really harmed a lot of people. And then suddenly they're like, we gotta do something about this. And then the US would basically create pathways to create more accredited versions of compounding pharmacies effectively. So that's like my guess on what happens. I don't think, and again, this kind of brings it back a little bit to the GLP-1 conversation, which is, there's another part of this, which is like the question of how does, how do we think about IP laws around drugs in general? Right? Where it's like, if I come up with a new drug and I'm like, hey, here is this new drug that cures joint pain. And someone is like, I'm going to make a compounded version of that and charge one tenth the price.

• 1:18:16Speaker 00

  What is even the point of having IP laws in the first place, right? So I think that brings up a very separate and interesting conversation. But this administration, I think, is more on the side of, we should just get, make things cheaper for everybody. And, you know, pharma basically is maybe losing that battle, sounds super clear to me. Or, and but, and the other thing with peptides is there's a whole range of them, right? There's peptides like retitrin, which is actually still being studied in clinical trials today. This is just sort of like a shortcut way to get them faster versus like totally unstudied ones that do god knows what, right? So, you know, if you go to these like bodybuilding subreddits and all that, they're always on the fringe of this stuff. Of course, it's a little bit of survivor bias.

• 1:19:00Speaker 00

  The guy who, you know, injected some random peptide is not posting on those forums anymore. Yeah, they're trying all this stuff. And question is, should we actually be capturing structured data from these people if they're doing it anyway?

• 1:19:12Speaker 01

  Totally. Well, so first of all, it ends up on a subreddit and then it ends up in an LLM.

• 1:19:16Speaker 00

  Yeah.

• 1:19:17Speaker 01

  And then you have an LLM that's saying, so you kind of dangerous loops there.

• 1:19:20Speaker 00

  Exactly.

• 1:19:21Speaker 01

  You know, this is a complex one because if you ban imports

• 1:19:26Speaker 00

  Yeah.

• 1:19:26Speaker 01

  of these peptides, then you're, you probably result in even more underground movement here. And then if you make, if you approve certain compounders as compound pharmacies as you're allowed to do this, then do you, are you informally suggesting that you're okay with this and then encouraging it? And so this is, it's complex.

• 1:19:51Speaker 00

  I mean, I think they are sort of doing that, right? Like it is the, it all falls under this, I think, general ideology around patients should be able to choose and patients should be able to absorb risk themselves in exchange for lower prices if they so choose to do so. Now, again, totally depends where we fall on the spectrum of do you think patients should be able to do that or not? Can they make good decisions here?

• 1:20:14Speaker 01

  This is the freedom versus public health argument and you know, it's as old as time. I think the thing you alluded to this, which is it would be a real tragedy if people are going to do it anyways, no matter what happens. And then we don't learn anything from it. So if people are going to do it, can we create what we've done with AI where we're creating, you know, in certain states are creating sandboxes.

• 1:20:34Speaker 00

  Yeah.

• 1:20:34Speaker 01

  Where we can learn from it.

• 1:20:36Speaker 00

  Yeah.

• 1:20:37Speaker 01

  Can we create that here too?

• 1:20:39Speaker 00

  Yeah.

• 1:20:39Speaker 01

  But the problem is the moment you open up the door a little bit, you're endorsing it.

• 1:20:42Speaker 00

  I know, exactly. If you're like, hey, listen, I mean, this is basically like the safe injection site version of peptides.

• 1:20:48Speaker 01

  Yes.

• 1:20:49Speaker 00

  So as soon as you say, hey, listen, send us your data, you're basically saying, go do it.

• 1:20:54Speaker 01

  Yeah.

• 1:20:54Speaker 00

  And I don't know, do we want that?

• 1:20:56Speaker 01

  Are we going to be taking peptides in 10 years? Really hard.

• 1:21:01Speaker 00

  Can I tell you an interesting?

• 1:21:02Speaker 01

  Please.

• 1:21:02Speaker 00

  So in the US, we run three phases of clinical trials, right? Phase one to test for safety in healthy volunteers. Phase two to test for efficacy to see if the drug actually works in small populations with the disease. Phase three to see if that replicates across larger populations and many geographies, blah, blah, blah.

• 1:21:18Speaker 01

  Right.

• 1:21:20Speaker 00

  There is a movement out there that is basically, and it's coming to the US now, actually, that is basically like, why do we have to test for efficacy at all? Why don't we just test for safety and then let the market decide what efficacy is? Right? So as soon as a drug is proven safe, then we should just be able to, I should be able to go get it if I want to, right? And you'll bring drugs to market way faster that way. And then the insurers will basically look at the efficacy data to see how much they'll pay and reimburse it. And then over time, you'll have more real world evidence to say, hey, this is working, this is not it, but people can make their own choice.

• 1:21:56Speaker 01

  Yeah.

• 1:21:56Speaker 00

  I'm not saying it's right or wrong, but like Montana, I believe, passed a law that allows you to do this, I think for gene and cell therapies, where you can, you know, I think, go and try and challenge gene therapy, basically if it's proven as just like doing phase one. And they've been doing this in the Honduras, in this, these like charter cities, to for, you know, gene therapies for folistatin and all this.

• 1:22:18Speaker 01

  This is the Brian Johnson.

• 1:22:20Speaker 00

  Yeah, exactly.

• 1:22:20Speaker 01

  Yeah, yeah.

• 1:22:21Speaker 00

  So that's, I mean, peptides are sort of an extension of that ideology a little bit, where you're like, maybe I should just be able to try this myself and see.

• 1:22:30Speaker 01

  You know, the libertarian sort of free market, you know, person in me likes that. But I think the challenge is then, okay, what are you allowed to market? So if you've only tested and demonstrated safety.

• 1:22:45Speaker 00

  Yeah.

• 1:22:45Speaker 01

  Then what are you allowed to say to convince and persuade?

• 1:22:48Speaker 00

  Yeah.

• 1:22:49Speaker 01

  People to try this thing? And can you make medical claims around efficacy if you haven't tested it?

• 1:22:52Speaker 00

  Yeah, that's a good question.

• 1:22:53Speaker 01

  You know, and then it's a slippery slope.

• 1:22:55Speaker 00

  Yeah.

• 1:22:55Speaker 01

  And you let that, you let one person make a claim and then all of a sudden.

• 1:22:59Speaker 00

  Yeah, yeah.

• 1:23:00Speaker 01

  The ones that truly are very efficacious become very difficult to decipher from all the ones that are just saying things.

• 1:23:07Speaker 00

  Yeah, I don't know. I don't know the answer to that. And again, this is like maybe where patient biobanks become interesting, where you're like, can I interrogate a registry of outcomes and see what it did anyway?

• 1:23:17Speaker 01

  Yeah.

• 1:23:17Speaker 00

  But not totally sure what they're gonna do about that.

• 1:23:19Speaker 01

  It feels more like food, too, where, you know, the, I'm not an expert in food testing, but.

• 1:23:24Speaker 00

  Yeah.

• 1:23:25Speaker 01

  You really just have to make sure it's safe.

• 1:23:27Speaker 00

  Yeah, supplements.

• 1:23:28Speaker 01

  Yeah, somewhat edible. But then you let the market decide if it's efficacious. Is that good? I mean, you know.

• 1:23:34Speaker 00

  I mean, everyone, no one likes the US food system.

• 1:23:36Speaker 01

  Is the US food system good? I don't know. So we're working on fixing that.

• 1:23:39Speaker 00

  Food has that concept of generally regarded as safe, right? Like then if as long as that, you can rip it.

• 1:23:45Speaker 01

  Yeah.

• 1:23:45Speaker 00

  Actually, maybe we should have swapped the two.

• 1:23:48Speaker 01

  Oh, gosh.

• 1:23:48Speaker 00

  And actually, food should have gone through more testing.

• 1:23:52Speaker 01

  Yeah.

• 1:23:52Speaker 00

  Before it comes to the system because it's at scale.

• 1:23:55Speaker 01

  Yeah.

• 1:23:55Speaker 00

  For everybody.

• 1:23:56Speaker 01

  Yeah.

• 1:23:56Speaker 00

  And then maybe drugs should have been generally regarded as safe.

• 1:24:00Speaker 01

  Yeah.

• 1:24:01Speaker 00

  Maybe that's the way we should have gone.

• 1:24:03Speaker 01

  Okay, so we covered some of your more spicy predictions. There's more in there that I thought were interesting. We don't have time for them.

• 1:24:09Speaker 00

  Yeah, yeah.

• 1:24:10Speaker 01

  Check them out if you're watching. We'll link in the comments here. But one, you were sort of predicting out of pocket. So tell, you know, what's going to happen out of pocket? And make a little prediction there.

• 1:24:19Speaker 00

  We're like all in on events now and in person and IRL. And I think, I think maybe this is like a broader content thing that's happening. But just, I'm just like not having phone on the internet anymore. I feel like AI has like really just distorted how we, how content is created. And then the algorithms are sort of boosting stuff that like doesn't bring me enjoyment anymore.

• 1:24:39Speaker 01

  The AI slop is killing you.

• 1:24:41Speaker 00

  AI slop is killing me. And like the, you know, when, when posts are like becoming a part of the zeitgeist, like it's just, now I'm getting mobbed rather than like having fun. Like the discussions are not as interesting to me.

• 1:24:51Speaker 01

  Yeah.

• 1:24:51Speaker 00

  And I'm not learning nearly as much online. And so we are all in on events now. And so we're doing hackathons. We're doing, we have this like micro conference format. That's like all workshop oriented, really role specific. And also like, you know, we're, we're actually doing a lot of like workshops, teaching people like interesting ways they can use AI in their work. So we're like doing a lot more in person stuff. And then also like for me personally, it's kind of interesting running like a creator focused business or something because it's hard to scale, right? It is like an interesting question of like, how do you scale a single person? We have been exploring a lot of AI tools ourselves internally. I've been Claude Code, just grinding, you know? And how do we use that in different parts of the business? Like scale up ourselves, basically.

• 1:25:35Speaker 00

  But yeah, really it's like a big focus on events this year and, and just doing more. For fun healthcare stuff, keeping healthcare fun, you know?

• 1:25:41Speaker 01

  Keeping healthcare fun. 2026, I mean, even since you wrote the article, just we, you know, we were at JP Morgan this week. The news is nuts. Things are happening at crazy pace. So at least in, probably in our careers, I'm sure you'd agree. This is the craziest time in healthcare period.

• 1:25:56Speaker 00

  I will say it is the first time, I mean, I've only been doing healthcare stuff for a decade. So like, take that with a grain of salt. But it's the first time it sort of seems like I see a path to either deflationary or flat spend in healthcare. Combo of AI, GLP-1s, you know, an administration that's kind of trying to focus on bringing costs more in line. It's just an ideology in the form of like consumer spend and all this kind of stuff. Like, I do see an interesting path now to maybe getting spend more in control. TBD, I mean, the timelines on that horizon are like very unclear, but there's just so much cool stuff happening.

• 1:26:35Speaker 01

  I'm equally as optimistic, but I see it differently on what happens.

• 1:26:39Speaker 00

  Okay.

• 1:26:39Speaker 01

  Which is that I think healthcare is going to get a lot, it's going to get a lot better, but we're going to spend even more on health. And it actually has nothing to do with what's happening in healthcare.

• 1:26:50Speaker 00

  Okay.

• 1:26:51Speaker 01

  And it's more just a function of what's happening to the country, which is as, you know, people thought that healthcare was going to bankrupt bankrupt us for a long time. But we keep spending more and more on healthcare because our GDP keeps going up. And we have more, you know, other things are getting a lot cheaper, electronics.

• 1:27:08Speaker 00

  Yeah.

• 1:27:08Speaker 01

  You know, basically, a lot of the industries that software has eaten have gotten a lot cheaper. And it allows a country to spend more of its money on other things that it values.

• 1:27:18Speaker 00

  Yeah.

• 1:27:19Speaker 01

  Healthcare, education, et cetera. And by the way, you know, real estate and a lot of those countries, a lot of those sectors have become a lot more expensive. You know, five, 10 years from now, are we going to be spending more on healthcare? I think we're going to be spending way more, but we're just going to get a lot more for it because these things are going to get better. We'll see. I think either way, it's a really fun time to be.

• 1:27:37Speaker 00

  Let me do a little further out prediction.

• 1:27:40Speaker 01

  Yeah.

• 1:27:40Speaker 00

  Sort of related to this, which is I, you know, as the US moved from a manufacturing-based economy, where that went overseas, we became a services economy.

• 1:27:51Speaker 01

  Yep.

• 1:27:51Speaker 00

  A big part of that trade was that healthcare basically became a jobs program to effectively replace manufacturing, right?

• 1:28:00Speaker 00

  Now, if we really want to see the productivity gains from AI, we have to figure out what the next thing is, post-services economy, right? And that's not just healthcare, that's for a lot of stuff, right? Like, you know, a lot of the jobs that are white-collar jobs are all we're already seeing is like, sort of, AI-able, right? So we need to figure out something that's like, a little bit post-services. One theory I have is that we are going to move to something that looks, it's hard for, I don't know exactly what the term is, but maybe it's like a community economy kind of thing?

• 1:28:32Speaker 01

  Creativity economy?

• 1:28:33Speaker 00

  Creativity, or just, you know, help your fellow person economy. And healthcare actually provides the existing rails to already do that. And one form of that, for example, is like paid caregivers, right? Or, I mean, what effectively almost looks like paid friends, essentially, right? Like, you see this in Medicare Advantage, where they'll pay people to like, come just take care of, you know, some of the older folks, etc. So actually, that might be the way that, you know, healthcare spend sort of absorbs a lot of this job loss, is just by basically saying, "Hey, we think that the way that, you know, the next economy going forward is like people just feeling good about their lives, and not necessarily just from a pure healthcare perspective,

• 1:29:16Speaker 00

  but healthcare provides the rails to do that, essentially." And that's why a lot of states have these paid caregiving programs, for example, that are some of the fastest-growing jobs in those states. So, you know, that might be one version of like, how healthcare spend increases.

• 1:29:32Speaker 01

  Yeah, I think the jobs thing and then what we spend are sort of two separate but very related things. Like, maybe we have fewer healthcare jobs in the way we define it today, as a percentage of overall, of the overall population and where people are working. But if it's something that we value more, and there's new, exciting stuff...

• 1:29:53Speaker 01

  And we can afford it.

• 1:29:54Speaker 00

  Yeah.

• 1:29:55Speaker 01

  Prices will rise, but we'll see.

• 1:29:56Speaker 00

  We'll see. Yeah, yeah. Well, I don't know. We'll, we'll, we'll still be in this industry if that happens. That's for sure.

• 1:30:02Speaker 01

  No doubt, and we'll be.

• 1:30:04Speaker 00

  Still faxing.

• 1:30:04Speaker 01

  Yeah, exactly. We'll be, we'll fax. We should have just done this podcast by fax.

• 1:30:07Speaker 00

  I know.

• 1:30:08Speaker 01

  That would have been more fitting. That would have been more fitting. A lot of people, you know, what I've seen, which I've been really excited about too, is technology broadly and people who are working in technology, there's an increasing percentage, this is anecdotal.

• 1:30:21Speaker 00

  Sure.

• 1:30:21Speaker 01

  Increasing percentage of people in technology that are coming into healthcare.

• 1:30:25Speaker 00

  Sure.

• 1:30:25Speaker 01

  They're interested. You know, I think stuff that you're doing to educate people about the complexity of healthcare, it's not actually that complicated. Come learn it. Come check it out.

• 1:30:33Speaker 00

  Yeah.

• 1:30:33Speaker 01

  A lot more people are entering, and I think that's awesome. I think that's why, you know, article, that's why I wanted to feature this predictions piece as an example of just, you know, there's cool stuff happening in healthcare. Come learn about it. Come make it, come make an impact. But in the age of AI slop, it's hard to figure out what to read and what to work on. So what is your content diet?

• 1:30:54Speaker 00

  Ooh, one thing that I've been doing recently is I'm going way back to primary source stuff now.

• 1:31:00Speaker 01

  Yeah.

• 1:31:01Speaker 00

  Partially because the AI tools also now make it easier to parse through like really long documents and just really focus on the parts that I want to focus on. But you know, like my most like old head behavior now is like I print out like a lawsuit and read it in the morning, or I get print articles or long form pieces or white papers and stuff. Like I'll print out and actually read it.

• 1:31:22Speaker 01

  Yeah.

• 1:31:23Speaker 00

  I think there is like actively more wrong information on the internet now than right information. Like I think that actually has tipped.

• 1:31:30Speaker 01

  Yeah.

• 1:31:30Speaker 00

  And so now it's time to go back to just reading the primary. And also I just am having more conversations with people directly where I'm just like, what are you experiencing? What's interesting about what you're doing? And I think, you know, just talking to people about the stuff they're working on and then following up on some of the things that they talk about is just way more fruitful and interesting now at this point versus trying to read online and believe that is truth. Like I have now crossed that Rubicon. So I read a lot of. White papers and stuff like that. And then there are a lot of Substack people and a lot of people who I think are doing a good job of writing like what I think is more sort of reliable information and learn a lot from them.

• 1:32:12Speaker 01

  Yeah, I've found LLMs have been a great translator of complex scientific white papers.

• 1:32:18Speaker 00

  Yeah.

• 1:32:19Speaker 01

  That if I'm not an expert in that domain, would just take me forever to parse through. And I just drop that into chat GPT or Claude or GROK or whatever and let it translate for me.

• 1:32:29Speaker 00

  Yeah.

• 1:32:30Speaker 01

  And then I can always talk to people about it and go and follow up, but the pace of stuff that is emerging right now, you can't keep up.

• 1:32:37Speaker 00

  No.

• 1:32:38Speaker 01

  You need an interpretation layer to our earlier conversations. So that's been.

• 1:32:41Speaker 00

  Yeah, exactly. Especially like if you, if you know a lot of the basics and you really just want to go to the more advanced stuff, like just remove all the basic stuff.

• 1:32:50Speaker 01

  Yeah.

• 1:32:50Speaker 00

  And just show me the stuff that's particularly interesting. And so it's been fun.

• 1:32:54Speaker 01

  It's awesome. Well, my man, I appreciate you coming on.

• 1:32:57Speaker 00

  Yeah. For people who don't know, by the way, I was like, yo, Jay, let's catch up. And Jay was like, yeah, man, let's do a podcast. And so that's like very class, you know, peak male relationship.

• 1:33:06Speaker 01

  This is the modern male relationship is if it's not recorded, why are we even doing?

• 1:33:10Speaker 00

  Yeah. Next time we'll have a peptide on the table and we can just take it together.

• 1:33:12Speaker 01

  Yeah. And we just show that on video too.

• 1:33:16Speaker 00

  Yeah, man. Thanks for having me. Appreciate it.

• 1:33:18Speaker 01

  Thanks for coming.

• 1:33:22Speaker 02

  Thanks for listening to the A16Z podcast. If you enjoyed the episode, let us know by leaving a review at ratethispodcast.com/A16Z. We've got more great conversations coming your way. See you next time. As a reminder, the content here is for informational purposes only, should not be taken as legal, business, tax, or investment advice, or be used to evaluate any investment or security, and is not directed at any investors or potential investors in any A16Z fund. Please note that A16Z and its affiliates may also maintain investments in the companies discussed in this podcast. For more details, including a link to our investments, please see A16Z.com/disclosures.