The real question is do we need commercial insurance carriers at all ? 72 pct of revenues for the biggest comes from carriers. Another chunk comes from self insured companies Does anyone have any data or research on how much risk the big insurance carriers actually take ?

Profit isn't the only signal. Feeling great about helping people. Changing people's lives. Helping your country. Putting people in a position to succeed. To enjoy their lives. People get to pick their own motivations. If they are fortunate, they will reach those goals. That's the beauty of capitalism. People get to choose the reward that motivates them. Entrepreneurs can choose to make as much money as possible. Or not. They can choose to make enough money to focus on using their most valuable asset, their time, to not have to work at all. They can choose to make money to help people. But. Every entrepreneur that wants to reach their goals needs people. People to work for them, buy from them, sell to them. Even the person in the basement with nothing but AI, needs to connect to humans to reach their personal goals. Capitalism works. But not for everyone. Where Capitalism fails people, Capitalism isn't the problem. It's the people that put profits above all else that are the problem. If you put your personal net worth or cash flow above all else, you may make insane amounts of money, but you will suffer the greatest indignity. You will be hated. Your time will not be your own. You will never experience the joy that comes from helping others. No one is born knowing where their life will take them. We get to do our best, in our circumstances, to try to enjoy our lives. Capitalism allows us to try to get there. Capitalism allows people who have achieved those goals to help others. Capitalism allows us to choose our own personal path. Unfortunately, we don't all get there. But we get to try to choose the path we want. The signal is personal choice. Not profit.

There are plenty. FAA, etc. Plenty they make worse too. But AI will be a great equalizer. So much of the friction and cost that bureaucracy introduces, can be eliminated by AI. Gov doesn’t have to make a profit. So AI used well, can allow services from all levels of gov to do some things better, for less cost than private companies. It won’t happen tomorrow, but if government agencies can find a way to use AI to optimize for the betterment of the people in this country (I know for many the default answer is no ), and are completely transparent about how AI is used, gov could look dramatically different in a decade

Multiple roommates. Ramen noodles. Near public transportation. Respect to the people who do whatever it takes. I worked as a bartender. Bar-back. $2.15 an hr plus whatever tips got shared. Worked at a retail store. Never had benefits at any job. Had 5 roommates in a 3 br apt. Ate lousy food out of cans and ate a ton of peanuts and shit food at happy hour. Had credit cards ripped up. Etc. But I learned a ton. Taught me what was right and wrong about running a business by watching my bosses and their bosses Yeah I know. It was much easier then, when inflation was 15 pct and national unemployment was 10 %. I know I was fortunate when I finally got fired from the store, and had to start my own business with zero cash. Bill collectors everywhere. Even luckier when I found my first customer so I could pay my bills But I recognize it’s so much harder today. Which is why I respect the people who are willing to do what it takes to get started

I use @bot all the time. I have the Luka plan (IYKYK). But I use all the majors. For general prompting 1. Claude 2. Chatgpt 3. Gemini For agentic work Replace Gemini with @bot They get trained and implement agents differently. I play them off of each other on anything important

Right or Wrong ? Switching costs for consumer AI, won't approach zero until there is a standardized export format for what is in a model's memory. The more a consumer uses a model, the more it's memory stores. The more work to export and import I'm not saying it can't be done. Obviously you can import from one model to another. But for regular users, that's a lot more difficult than saving to an xls or doc file Curious what people think ?

My testimony today at the Texas State capital I’m the co-founder of We started Cost Plus Drugs because the prescription drug market is too complicated, too opaque and too expensive. Our model is simple: we show what we pay for a drug, add a transparent markup and pharmacy fee, and show the customer the price. No games. No hidden spread. And a large percentage of our customers already have insurance. They come to us because our cash price is often lower than what their insurance plan asks them to pay. That tells you something is wrong. Here are five things Texas can do about it. 1. Let patients shop for cheaper drugs If someone's insurance says a prescription costs $500, but they can buy the exact same drug for $100 cash, let them buy it for $100. Then credit that $100 toward their deductible and out-of-pocket maximum wherever Texas has authority to do so. Patients should be rewarded for saving themselves and their health plan money. They shouldn't be punished for it. That's how you create something healthcare desperately needs: Price competition. 2. Standardize PBM and TPA contracts Texas should require the state, cities, counties and school districts to use standardized model contracts and mandatory terms for PBMs and TPAs. I've reviewed these contracts. They routinely run hundreds of pages. I've seen contracting packages longer than a thousand pages. There is no human being—or group of human beings—on this planet who can stay awake and understand every provision in contracts that complicated. I don't care how much coffee they drink. I call it contractual terrorism. The vendor only has to sneak a couple of tricks through hundreds of pages. The employer has to find every one. It can't. I've developed a model PBM contract designed to eliminate the major tricks and hidden economics we've identified. Texas can have it for free. Use mine. Improve it. Open source it. I don't care. Just stop making every government entity negotiate these contracts from scratch. 3. Make the economics public If taxpayers are paying the bill, taxpayers should know the price. Pricing. Fees. Rebates. Guarantees. Pharmacy reimbursement. Affiliate compensation. Audit rights. Make them public. I'm not talking about patient information or legitimate security information. I'm talking about the money. You cannot have an efficient market without price discovery. Without price discovery, you get information asymmetry. And when one side knows dramatically more than the other, guess who wins? Not taxpayers. Not employers. Not patients. Open the contracts up and let competitors see what they have to beat. That giant sucking sound you hear will be money moving away from healthcare conglomerates that are too big to care and back toward taxpayers, employers and patients. In the immortal words of Charles Barkley: I guarantee it. 4. Kill the gag clauses PBM contracts are like Fight Club. The number one rule of Fight Club is that you can't talk about Fight Club. The number one rule of many PBM contracts seems to be that you can't talk about your PBM contract. That's insane. Let employers compare pricing, rebates, fees, guarantees and reimbursement terms. Markets work better when buyers know what other buyers are paying. 5. Make enforcement hurt If a healthcare company commits a serious violation, give them one mulligan. But after a second material federal or Texas enforcement action within a defined period, make them ineligible for new Texas government contracts for a period of time. Two strikes. You're out. Today, some of these companies can make billions, get caught, pay a fine and write it off more easily than I wrote off an NBA fine. That's not deterrence. That's a cost of doing business. And Texas should spend more on enforcement. If Texas spends $10 million auditing contracts and analyzing claims and prevents $100 million in unnecessary spending, that's not overhead. That's a 10x return on investmen

Ro, that’s insane. You want the state to loan money to the founder, who will then immediately give it back to the state as a wealth tax ? Meaning the state has not received any incremental receipts? What’s the point of that ? Unless of course you want the gov to own shares (something I thought you criticized) and possibly have control, of companies who underperformed, (or the funding market changed), and couldn’t pay back their loans over those 10 years ? And I’m sure the investors in those companies will be thrilled about their new partners. That will make for interesting board meetings. “Today’s first topic is trying to figure out how to motivate the founder(s). They just lost $250m of their shares in the company they founded, to the state of California. Anyone got any ideas ? “ But at least it’s amazing for state’s brand. “Cali, You make it. We take it !” Come on Ro. Ideology is not a strategy. @GavinNewsom

Ro, I like you. You know that. But you need to read the state of the state. The number of Deca Unicorns in Cali is growing by the day as investors chase amazing startups. A unique feature of these 10b startups is that even if they raise a billion, little, if any of that money goes to the founders, who are now worth billions of dollars over night. They are the definition of cash poor, stock rich How are you going to tax them ? Make them borrow money against their shares, if they can? They just raised money to grow their company and a bank will come along and loan them money ? A company that has been in business maybe less than a year ? lol Will you take their stock if they can’t ? Do you really think each of multiple founders, who started an amazing company in Cali and is now a billionaire, can each just pull out $250m per billion of net worth from their raise ? You know they can’t. If this passes , and it doesn’t directly impact me at all, I won’t be a cali resident, but you can bet if I’m investing in a multi billion dollar startup, I’m asking them to move from California first. IMO, if this passes, only idiot startup founders stay in Cali. I’ve done it before and will do it again. Dallas. Pittsburgh. Indiana. I will make NOT being in California a pre requisite for an investment Ideology is not a strategy Ro.

It’s time for everyone to realize that the fight against data centers has nothing to do with data centers. They have become a proxy for the hate towards AI and the concentration and accumulation of wealth it’s creating. Until those running the big LLMs understand this and start a community tour, not to explain the benefits of AI, it’s too late for that, but to help towns and cities that may be impacted by job losses (and I’m a believer their will be a net gains in a few years), this battle is only going to get more intense and let me tell you now , no matter how much money you pay to buy politicians and races, you will lose. One thing I have learned is being hated is not good for business. How can they help ? They will tell you. You will need to do what they ask. Billions of dollars is a lot of money across towns and city programs. Across the major LLMs, it’s a cost of doing business. At the same time, I would go to LA and NYC and ask the arts and creative unions what kind of programs would help and protect their artists. DO NOT GO TO THE MUSIC OR FILM COMPANIES. that will make it worse. Don’t try to pay famous people to endorse what you are doing. That’s dumb. Talk to artists and ask them what you can do to provide financial and creative support. Every creative I know is TERRIFIED about what AI will do to their profession. You must meet them face to face and basically do what they say. The big LLMs have lost the PR battle. Why ? Because they all suck at putting people first. They have an SV attitude that makes them all think they are John Galt saving the world Given the number of data centers and power that is needed, today and going forward , If you don’t kiss the asses of the people that go to work every day, and are just trying to pay their bills, you will fall far far short of the capacity you need to make your business work.

Everything in the hospital could cost $1, and the insurance companies conglomerates would buy them, raise prices, and make sure their top and bottom lines grew I'm not saying hospital systems are innocent, far from it. But the big vertically integrated insurance companies create the annual plans that crush people's financial situation

You aren't wrong that premiums are a healthcare tax, of which a too high percentage goes to the insurance conglomerates. But you left out a lot of important information 1. Who would run M4A, and how would that person(s) be selected and how often? Right now the Sec of HHS has discretion over everything, and we appoint a new one every 4 to 8 years, or more.. The implications are obvious. 2. What is not covered ? Is every $4m therapy going to be covered ? Even when you negotiate, it won't be cheap. What about the most expensive life saving equipment? It's not like the feds are good at negotiating healthcare 3. Who gets paid less ? Doctors ? Nurses? Specialists? 4. You assume employers will pass along what they don't pay for their share of benefits, to the employee. Do you live in the USA ? This assumption is unfortunately laughable and nothing in an M4A bill can change that 5. Much of medicare/medicaid is run by outside companies. Many of whom are the very worst actors in the healthcare industry. How do you replace them all ? How many years do you think that will take ? or Do you expect them all to become good actors and do the right thing rather than try to maximize earnings? 6. Hospitals don't know what their procedures cost them to perform. They use derivative cost accounting like cost to charge ratios, or, only show Medicare Cost Reports, and basically just look at how much cash they have on their books. Which is one of the reasons they are able to say they don't make money from Care/Caid patients. I don't think many understand what the concept of margin contribution is. If they don't know what their costs are, and you don't know what the actual costs are, how are you going to be able to work from a budget to determine total costs ? That said, Im for Universal Coverage. But till you know what it actually costs to deliver care in this country, its going to be near impossible to make work How do other countries do it ? Most started on this 30 years or more ago. Pre MRI machines. Pre Cell and Gene Therapies. They were able to start at a time when healthcare was much simpler, and evolve, some successfully, some less so, from that point. This is my opinion. If you disagree with any of it, happy to read it here

I’m coming to the conclusion that the biggest challenge for Enterprise AI, and AI in general , as of now, is that it’s still impossible to make sure that everyone gets the same answer to the same question, every time. Which is a great response to the doomers. AI doesn’t know the consequences of its output. Judgement and the ability to challenge AI output is becoming increasingly necessary, and valuable. Which makes domain knowledge more valuable by the second. Am I wrong ?

If the people doing this, from @elonmusk on down, are honest about their intentions, they should have zero problem publishing EVERYTHING they are doing on a daily basis i absolutely want to see @Doge reduce wasteful spending. But i want the process to be transparent.. I don't want to have to guess which media reports are accurate or not. If this is the result of a detailed plan. I want to see the plan. If this is legal. I want to see the law that supports it. If there are questions about whether it is, I want to see the opposition. This isn't a shock and awe attack on foreign soil. This is a shock and awe attack on American Systems and Economics. That doesn't mean it shouldn't happen. But if it should, then it should be 100 pct transparent. If they hide anything, they are doing it wrong. If they hide anything, that means the goals is not the interest of the American People. We were promised transparency. We should see everything