In a speech to the American Philosophical Society in January, 1946, J. Robert Oppenheimer said, “We have made a thing …that has altered abruptly and profoundly the nature of the world…We have raised again the question of whether science is good for man, of whether it is good to learn about the world, to try to understand it, to try to control it, to help give to the world of men increased insight, increased power.”
Eight decades later, those words reverberate, and we once again are at a seminal crossroads. This past week, Jensen Huang, the CEO of Nvidia, was everywhere, a remarkably skilled communicator celebrating the fact that his company was now the first publicly traded company to exceed a $4 trillion valuation.
As he explained, “We’ve essentially created a new industry for the first time in three hundred years. the last time there was an industry like this, it was a power generation industry…Now we have a new industry that generates intelligence…you can use it to discover new drugs, to accelerate diagnosis of disease…everybody’s jobs will be different going forward.”
Jensen, as I observed him perform on that morning show, seemed just a bit overwhelmed, awed, and perhaps even slightly frightened by the pace of recent change. “We reinvented computing for the first time since the 60’s, since IBM introduced the modern computer architecture… its able to accelerate applications from computer graphics to physics simulations for science to digital biology to artificial intelligence. . . . in the last year, the technology has advanced incredibly fast. . . AI is now able to reason, it’s able to think… Before it was able to understand, it was able to generate content, but now it can reason, it can do research, it can learn about the latest information before it answers a question.”
Of course, this is hardly the first time technology has triggered flashing ethical warning lights. I recently summarized the case of Facial Recognition Technology (FRT). The US has the largest number of closed circuit cameras at 15.28 per capita, in the world. On average, every American is caught on a closed circuit camera 238 times a week, but experts say that’s nothing compared to where our “surveillance” society will be in a few years.
What’s behind the coming health care reckoning? Most industry leaders have their preferred list of culprits: not us! Left-leaning critics blame large insurers, drug companies, and private equity firms. Take the profit and self-dealing out of health care. Those on the right blame excessive regulation, poorly-designed insurance markets, or limits on individuals’ ability to pick their own coverage. Debates yo-yo between these views in a political stalemate. While the views are diametrically opposed on solutions, they share a belief that financial issues are the root cause of systemic dysfunction. That manipulating how clinicians are paid or insurance is structured can improve health outcomes.
A half century into efforts to fix health care, it is clear that both views are wrong. Americans’ healthspans are shrinking while costs spiral upwards thanks to chronic disease. Progressively worsening illness throughout adulthood eventually explodes in multimorbidity, driving cancer and dementia, and protracted hospitalizations. Clinicians know this, with their well-worn chorus of “if only” laments. If only we could reward prevention instead of treatment. If only we intervened earlier before advanced pathology takes hold. If only clinical care was not fragmented. If only people had a direct stake in their longer-term health. Yet the debate in Washington DC, even shaken up by the MAHA movement’s focus on chronic issues, regresses into an interminable blame game, and conflicting ideas about how Congress or CMS could end the madness.
It is time to break the cycle and say clearly what we know to be scientific fact. It’s impossible to use a system built to solve acute issues to also solve multi-decade, highly variable disease threats. Yet this presumption, that one system can do it all, addressing everything from colds to car crashes to cardiovascular issues to cancer, is so deeply ingrained in our thinking as to escape scrutiny.
It is folly to continue. We need two systems, not one — the first for routine, emergency, and elective treatments and the second to confront long-term, complex challenges. Absent this change it will take far longer than it should, and cost far more, to decipher chronic issues or create economic arrangements that can bring forward the ultimate value of preventing disease.
Resetting Assumptions
It’s illuminating to focus on the scientific drivers of disease rather than the financial after effects. It becomes clear why Medicare Advantage is imploding, and no, it’s not because CMS changed payment rates. Since 2000, the percent of Americans entering Medicare with multimorbidity has jumped by two-thirds, from a quarter of new entrants to over 40%. Software may be eating the world but multimorbidity is eating Medicare, Medicaid, and private insurance, and with it, most Americans’ healthspans.
Most Americans now live a decade more than their grandparents, only to spend all the additional years, and then some, in poorer health.
If you want to hear a little about Commons Clinic from Benjamin Schwartz, MD but rather more from me about who knows what, it’s on The Surgeon’s Record podcast — Matthew Holt
On March 9, 1967, the Star Trek classic episode, “The Devil in the Dark” first aired. The Enterprise had received an urgent distress call from miners on the planet Janus VI. They are literally melting after, Horta, a wounded inhabitant has targeted them with liquifying acid rays.
A sympathetic Spock hears the call, and in an effort to disclose cause and motivation, “mind-melts” with the creature. Turns out, all she’s trying to do is protect her babies from a perceived threat. Kirk agrees, and with Spock, calls in Dr. McCoy to access the patient’s condition.
What McCoy encounters is a “rocky-skinned patient.” With the aid of his tricoder, a handheld diagnostic sensor, “Bones” (McCoy’s nickname referencing the historical 19th century American slang “Sawbones” referring to surgeons) uncovers a serious and deep gaping wound that requires immediate attention.
Kirk manages to “beam down” a hundred pounds of thermoconcrete, and McCoy expertly applies it to the wound. All of which is a set-up for his shipmates to wonder if this will work, which generates the iconic most-repeated line in the series storied history. McCoy (clearly irritated) utters – “How do I know? I’m a doctor, not a bricklayer.”
Similarly challenged modern day doctors have been voicing their own frustrations for more than a few decades. But the AMA has been scientifically tracking their discontent only since 2011. The levels of burnout are somewhat down in 2025 compared to peaked pique in 2021. But among the irritants, integration of new technology remain near the top of the list.
My friends, we are like explorers of yore standing at the edge of a known continent, looking out at the vast ocean in hopes of finding new, unspoiled, better lands across it. True, we may have despoiled the continent behind us, but certainly things will be better in the new lands.
In the metaphor I’m thinking of, the known continent is our shambles of a healthcare system. For all the protestations about the U.S. having the best health care in the world, that’s manifestly untrue. We don’t live as long, we have more chronic diseases, we kill each other and ourselves at alarming rates, we pay way more, we have too many people that can’t afford care and/or can’t obtain care, we have too much care that is ineffective, inappropriate, or even harmful, and we spend much too much on administration.
Across that metaphorical ocean, in the distance, over the horizon, lies the 22nd century healthcare system. It will, we hope, be like magic. It will be more equitable, more effective, more efficient, more proactive, less invasive, more affordable. We don’t know exactly what it will look like or how it will work, but we’ve seen what we have, and we know it can be better – much better. We just need to get there.
This leads me to the next part of the metaphor. I recently read a great quote from the late nature writer Barry Lopez, from his posthumous book of essays Embrace Fearlessly the Burning World. Mr. Lopez laments: “We are searching for the boats we never built.”
The boats aren’t coming to save us, to transport us to that idealized 22nd century healthcare system. Because we never built them. Because we still don’t have the courage to build them.
We’ve never built a system to ensure universal coverage. We rely on a hodgepodge of coverage mechanisms, each of which is struggling with its own problems and still leaving some 25 million people without insurance – and that’s before the 10-20 million who are predicted to lose coverage due to the “Big, Beautiful Bill” – plus the tens of millions who are “underinsured.
We’ve never built a system that was remotely equitable, just as we never did for housing, education, or employment. Money matters, ethnicity matters, geography matters. Discrepancies in availability of care and in outcomes show up clearly for each of those, and more.
We’ve never built a system that prizes patients above all. We deferred to doctors and hospitals, not calling them out when they gave us substandard care or when they charged us too much. Now health care has gone from a “noble calling” to a jobs and wealth creator. A recent New York Times analysis found (among other things):
Health care is the nation’s largest employer;
In 1990, health care wasn’t the largest employer in any state; now it is in 38 states;
We spend more on health care than on groceries or housing.
Pick your favorite target: private equity firms buying up health care entities, for-profit companies extracting profits from our care (or nominal “non-profits” doing the same), the steady corporatization of health care. Throw in favorite boogeymen like health insurers, PBMs, or Big Pharma. One way or another, it’s about the money, not us.
The adage about Big Tech comes to mind: we’re not the customer, we’re the product (or, as I’ve written before, we’re simply the NPCs.).
We’ve never built the systems to make administration easier. So many codes, so many rules, so many types of insurance, so many silos, so many administrators. By now you’ve no doubt seen the chart of the growth of administrators versus clinicians in our health care system, and are aware that around a quarter of our healthcare dollar goes to administration. It doesn’t have to be this way, it shouldn’t be this way, but administrative bloat is getting worse, not better.
We’ve never built the systems to properly track our health or risks to it.
We are entering an age of at home testing and the team at Reperio just raised $14m to make weight, blood pressure and cholesterol/blood sugar testing available at home. But this is a relatively complex series of tests, intended to get people who haven’t been to a primary care doctor back into the system. How is the experience and can we expect people to do it? And does the result correlate with standard lab testing? They sent me the box for me to find out. I totally screwed it up the first time (apparently only 4% of people do), but they gave me another chance. So come along with me to find out how it works. Would you do this, or just go to Labcorp?! — Matthew Holt
BTW since I did this Reperio released an early customer study that said 23% of those who used the kit found a problem they weren’t aware of. Which is I guess the point!
In the wake of last week’s human tragedy in Texas, it would be easy (and appropriate) to focus on the role played by Trump’s reckless recent dismantling of FEMA and related federal agencies. But to do so would be to accept that the event was an anomaly, or as Trump labeled it on Sunday on his way to a round of golf at Bedminster, “a hundred year catastrophe.”
In reality, tragedies like this are the direct result of global warming, and last week’s suffering and loss are destined to be followed by who knows how many others here and in communities around the world.
In 2009 President Obama joined global leaders in New York City for the Opening Session of the UN. One of the transboundary issues discussed was Global Warming. All agreed that the Kyoto Protocol had failed. It failed because the target to decrease emissions by some 5% was too low. It failed because large transitional nations like India and China were excluded. And it failed because US leadership opted out.
The global community today has a deeper hole out of which it must dig. In doing so we would do well to focus on health and safety as outcome measures, and define strategies to manage the obvious consequences of this ongoing crisis.
Two decades ago, the warnings were clear. Left unattended, we would soon not only need to plan mitigation, but also need to prepare and resource intervention to deal with inevitable human injury and disease fall-out. Of course, back then, we could not have predicted that wise disease interventions in climate ravaged hot spots around the globe, like expansion of USAID funding in the Bush and Obama administrations, would be X’d out under Trump/Musk. Who could have imagined such reckless and ultimately self-destructive moves?
Most of us know the story of the Model T – but what’s often overlooked is how it applies to other industries, especially digital health. Let’s revisit:
In the early 1900s cars were custom built. You’d meet with a consultant, design the car, place your order, and wait for months for delivery. Once your car was delivered, it was difficult to operate. Many owners hired chauffeurs because at the time, cars required technical know-how, constant maintenance, and a fair bit of strength (power steering wouldn’t arrive for decades).
Then came the Model T in 1908, which led to Ford developing his assembly line in 1913. He recognized a problem in the industry and saw an opportunity. He saw the opportunity for scale:
Standardization: “Any color, as long as it’s black“
Mass production = affordability: Prices dropped from $850 in 1908 to $300 within a decade
Accessible ownership: anyone could walk into a Ford dealership and drive away
Left: Early car assembly (pre-Ford) Right: A leading digital health interface, 2000
On the right side of the above image is a cutting-edge digital health program from August 2000. I know it well – because I helped build it. Since then, I’ve worked on well over 100 digital health interventions. Probably closer to 200. Here’s the thing: what’s inside hasn’t changed very much. Behavioral science doesn’t move that quickly (although my recent work in AI is changing that).
And yes – digital interventions look better, are easier to navigate, and coding languages have evolved – but practically, digital health is still building custom cars – not Model Ts. That’s why tens of millions can’t open a browser and get the help they need.
What’s Blocking Digital Health’s Model T Moment?
1. Enterprise Sales (Death by Pipeline): Most digital health tools are sold through enterprise channels: RFPs, procurement departments, tenders, security reviews, and legal teams. The average sales cycle is 6-18 months. That’s fine for a $5M contract, but it’s lethal for a $50,000 contract. The problem isn’t the product – it’s the process.
2. The Vanishing Champion: I’ve experienced this dozens of times, and I’ve taken deep breaths watching it unfold on webinars: a digital health company demos their solution alongside a client champion. Priorities shift. The champion leaves. The reference project dies. Most contracts aren’t lost on merit – they’re lost to turnover.
3. Healthcare Pricing ≠ Software Pricing: Most patient-facing tools are priced like services, not products. That’s a symptom of the enterprise sales trap. Vendors charge annual fees regardless of usage. Clients expect hand-holding for these custom products. Pricing needs to reflect modern SaaS models – freemium, tiered access, per-user billing.
4. Static Products in a Dynamic World: Consumer software updates weekly – sometimes daily. Digital health tools? They launch, then stall. Feedback loops are weak. There’s no culture of iteration, and no expectation of continuous improvement.
5. Nobody Markets to the User: The best-designed tools fail if no one uses them. Lack of engagement is a systemic issue, yet many programs are launched without onboarding plans, email campaigns, or even prewritten content for TikTok or Instagram. Users don’t know what the tool is, why they received access to it, how they access it, or how it fits into their care. That’s not a product issue – it’s a marketing failure.
We Need to Build the Systems, Not Just the Tool
Henry Ford didn’t invent the automobile, but he’s remembered because he built a system. He looked beyond the engine, the chassis, and the tires. He focused on standardization, distribution, and access.
Digital health needs the same. Right now, too many solutions are trapped in a loop – custom-built for small populations, sold through enterprise channels, with no realistic path to scale.
The Good News? We’re Close
Cloud infrastructure, AI, and behaviorally intelligent platforms are finally catching up. We can now personalize at scale, launch instantly, track engagement in real time, and iterate fast. But to get there, we have to let go of the custom-built carriage mindset and embrace the assembly line. That’s not a compromise in quality – it’s a commitment to reach.
We don’t need more pilots – we need platforms.
We don’t need more bespoke builds – we need scale.
Digital health doesn’t have a technology problem – it has a delivery problem.
Until we achieve that, we’re just making nicer carriages – while the world waits for its Model T.
Dr. Trevor van Mierlo has built mental health and patient support products for more than two decades and is the CEO of Evolution Health
As a DNA-based creature myself, I’m always fascinated by DNA’s remarkable capabilities. Not just all the ways that life has found to use it, but our ability to find new ways to take advantage of them. I’ve written about DNA as a storage medium, as a neural network, as a computer, in a robot, even mirror DNA. So when I read about the Synthetic Human Genome (SynHG) project, last month, I was thrilled.
The project was announced, and is being funded, by the Wellcome Trust, to the tune of £10 million pounds over five years. Its goal is “to develop the foundational tools, technology and methods to enable researchers to one day synthesise genomes.”
The project’s website elaborates:
Through programmable synthesis of genetic material we will unlock a deeper understanding of life, leading to profound impacts on biotechnology, potentially accelerating the development of safe, targeted, cell-based therapies, and opening entire new fields of research in human health. Achieving reliable genome design and synthesis – i.e. engineering cells to have specific functions – will be a major milestone in modern biology.
The goal of the current project isn’t to build a full synthetic genome, which they believe may take decades, but “to provide proof of concept for large genome synthesis by creating a fully synthetic human chromosome.”
That’s a bigger deal than you might realize.
“Our DNA determines who we are and how our bodies work,” says Michael Dunn, Director of Discovery Research at Wellcome. “With recent technological advances, the SynHG project is at the forefront of one of the most exciting areas of scientific research.”
The project is led by Professor Jason Chin from the Generative Biology Institute at Ellison Institute of Technology and the University of Oxford, who says: “The ability to synthesize large genomes, including genomes for human cells, may transform our understanding of genome biology and profoundly alter the horizons of biotechnology and medicine.”
He further told The Guardian: “The information gained from synthesising human genomes may be directly useful in generating treatments for almost any disease.”
Professor Patrick Yizhi Cai, Chair of Synthetic Genomics at the University of Manchester boasted: “We are leveraging cutting-edge generative AI and advanced robotic assembly technologies to revolutionize synthetic mammalian chromosome engineering. Our innovative approach aims to develop transformative solutions for the pressing societal challenges of our time, creating a more sustainable and healthier future for all.”
Project member Dr Julian Sale, of the MRC Laboratory of Molecular Biology in Cambridge, told BBC News the research was the next giant leap in biology: “The sky is the limit. We are looking at therapies that will improve people’s lives as they age, that will lead to healthier aging with less disease as they get older. We are looking to use this approach to generate disease-resistant cells we can use to repopulate damaged organs, for example in the liver and the heart, even the immune system.”
Anmol Madan is CEO of RadiantGraph. He’s building an end to end solution that goes from data ingestion to applications to consumer connection via text/email and voice in order to let payers quickly roll out patient engagement plans. His idea is that plans/payers don’t need to fix their data, RadiantGraph’s AI can take the messy data and and then add an AI layer, and on that create specific applications–Anmol showed me a comprehensive demo. I also asked him if they are doing too much, or conversely if they need to do more!–Matthew Holt
