“We should all be able to look at the numbers and agree that this is not sustainable and that whatever we’ve been doing is not working. Democrats have had their chance, and Republicans have had their chance, and it’s only gotten worse.” — Halle Tecco

Warren Buffett called America’s healthcare costs “a hungry tapeworm on the American economy.” That tapeworm now devours nearly a fifth of the nation’s GDP—and the patient, as always, is on the table. We dedicate today’s show to this most perennial of all America’s problems, with two guests and two new books that approach the tragi-comedy from different angles.

Self-styled innovation wonk Halle Tecco—founder of Rock Health, investor in over fifty digital health companies, professor at Columbia Business School—argues in Massively Better Healthcare that the system is both excessively public and excessively private, a Kafkaesque bureaucracy in which verticalized health plans now own the PBMs, the pharmacies, and increasingly the doctors. The result is monopoly medicine on a scale that would have appalled the original trust-busters.

This is ultimately an antitrust story. As we’ve discussed on the show with Tim Wu, Biden’s chief antitrust enforcer, the concentration of corporate power is the great unfinished business of American democracy. Tecco makes the case that Big Med is where the trust busters should go next after Big Tech. UnitedHealth is now one of the largest employers of doctors in the country. So it wasn’t exactly shocking when the UnitedHealth CEO was assassinated two years ago. The system isn’t broken, Tecco suggests. It’s working exactly as designed—just not for patients.

Surgeon Robin Blackstone, MD, author of Doctor AI: Reimagining Health. Rebuilding Trust. Delivering Health 4.0, joins us in the second half of the show to offer a view from the front lines. After 30 years as a surgeon, Blackstone confirms everything Tecco diagnoses—and adds a chilling detail of her own: the system is priced entirely for fixing illness, not preventing it. Her prescription is a “triangle of trust” between patient, physician, and AI—with the patient finally owning their own data.

Both agree on one thing: every dollar spent on public health saves $14.30 in medical and societal costs. We are all already paying for all the waste. We just need to fix Big Med. But who’s going to do it? Tecco says that America is ready for another round of Obamacare politics. But I’m not so sure.

Five Takeaways
• Healthcare Is a Tale of Two Civilizations: 100 million Americans lack a regular primary care provider. Healthcare debt is the #1 cause of bankruptcy. A $30K earner in a rural county lives a decade less than a $100K suburbanite.
• The Real Winners Are Monopoly Medicine: Verticalized health plans own the PBMs, pharmacies, and providers. Independent pharmacies close at one per day. Rite Aid—the only chain not owned by a health plan—is bankrupt.
• Every $1 in Public Health Saves $14.30: Public health’s share of spending has dropped 25% in two decades. We’re paying for the crisis downstream. We just need to move the safety net upstream.
• AI Could Break the Information Asymmetry: Patients are already using ChatGPT to diagnose themselves. One woman caught her own pneumonia. But some doctors want to keep the paternalism.
• The System Is Priced for Rescue, Not Health: Prevention doesn’t get paid for. Both guests agree: we need a massive re-pricing that rewards keeping people healthy, not just treating them when they’re sick.

About the Guests
Halle Tecco is the founder of Rock Health and an adjunct professor at Columbia Business School. Her new book is Massively Better Healthcare (Columbia University Press).
Robin Blackstone, MD, is a surgeon and health systems architect. Her new book is Doctor AI: Reimagining Health. Rebuilding Trust. Delivering Health 4.0.

References
Robert Pearl on AI healthcare: https://keenon.substack.com/p/back-to-the-digital-future-why-the
Tim Wu on platform capitalism: https://keenon.substack.com/p/why-the-real-road-to-serfdom-runs
Zeke Emanuel on best healthcare: https://keenon.substack.com/p/ezekiel-emanuel-which-country-has-40d

About Keen On America
Nobody asks more awkward questions than the Anglo-American writer and filmmaker Andrew Keen. In Keen On America, Andrew brings his pointed Transatlantic wit to making sense of the United States.
Website: https://keenon.tv/ Substack: https://keenon.substack.com/ YouTube: https://youtube.com/@KeenOnShow