Chapter 4
There is no shortage of innovation in healthcare right now.
Artificial intelligence is accelerating discovery in ways that would have sounded impossible just a decade ago. Genetics and blood based tests can identify disease earlier and with greater precision. New therapies are moving through pipelines at record speed, backed by capital, partnerships, and increasingly sophisticated science. From the outside, it looks like a system that is finally doing what it was supposed to do.
And yet, many patients still cannot access care that already exists.
That contradiction sat at the center of a recent panel on the “Future of Healthcare Access and Equity”. What made the discussion compelling was not technical depth or flashy forecasts, but how openly the speakers spoke about the growing gap between what we are capable of building and what actually reaches people in real life.
One speaker grounded the conversation early with a reminder that cut through everything else.
“Let’s remember it’s always about the patients at the end of the day. And every single person on this planet is a patient.”
The issue, as the panel made clear, is not a lack of ideas. It is the way the system itself is structured.
Innovation is moving fast. Access is not.
Over the past few years, biotech has made enormous progress. We can detect disease earlier, design more targeted drugs, and run smarter and more efficient trials. Capital continues to flow, deals continue to close, and the science continues to improve.
But innovation only matters if people can actually use it.
As one panelist asked bluntly, a question that lingered throughout the discussion,
“What good are your innovations unless people can afford them?”
Sitting uncomfortably alongside that question is another reality the panel did not shy away from. Without the ability to generate returns, innovation slows down. The tension between affordability and sustained progress is real, persistent, and often avoided in public conversations, but pretending it does not exist only pushes the problem further down the road.
The system rewards the wrong things
One of the clearest themes was how poorly healthcare incentives align with long term health outcomes.
Most decisions are made on short time horizons. Budgets reset annually. Coverage changes frequently. Responsibility is fragmented across insurers, employers, governments, providers, and patients. When everyone owns a piece of the problem, no one truly owns the outcome.
As one speaker put it, with refreshing simplicity,
“The happy medium is the wrong place. That’s why incentives are a mess.”
There are exceptions. Employer sponsored health plans were highlighted as one of the few areas where incentives sometimes align more naturally. When employers carry healthcare costs over many years, they have a reason to invest in prevention, mental health, and early intervention, rather than focusing solely on short term fixes.
For founders, this matters more than it may initially appear. The success of a health product is not only determined by clinical efficacy, but by whether someone has a reason to pay for it before a condition becomes severe, expensive, or irreversible.
Clinical trials still leave people out
Access challenges begin long before a drug ever reaches the market.
Clinical trials remain expensive, slow, and often designed around patients who have time, money, transportation, and flexibility. That design reality systematically excludes the very populations who could benefit most from new therapies.
One speaker put it plainly.
“We are systematically excluding patients who could most benefit, and we’re making it expensive and slow to bring treatments to market.”
Digital tools such as wearables, remote monitoring, and real world health data were framed not as trends, but as practical opportunities to reduce friction, lower costs, and make trials more representative of real patients.
The technology is no longer the limiting factor. The challenge now is changing entrenched habits and assumptions.
Direct to consumer sounds good until it doesn’t
Direct to consumer healthcare models came up repeatedly, particularly in the context of highly visible drugs like GLP 1s.
On the surface, these models appear to offer progress. Fewer steps, faster access, telemedicine, and home delivery can meaningfully reduce barriers for certain patients.
But the panel pushed back hard on the idea that DTC is a universal solution.
The concern is not convenience, but cost shifting. In many cases, DTC does not reduce the price of care, it simply moves the burden from insurers to patients. Access improves for a small group while worsening for many others.
That tension is already influencing behavior in unexpected ways.
“People are choosing where to work based on whether a GLP 1 is covered,” one panelist noted.
Convenience matters. But without thoughtful coverage strategies, direct to consumer models risk deepening inequity rather than solving it.
The quiet role of middlemen and cash pay
Middlemen in healthcare, particularly pharmacy benefit managers, are often framed as villains. Sometimes that criticism is justified. They can add opacity, drive up costs, and complicate access.
But the panel cautioned against oversimplifying their role. Middlemen also negotiate pricing, manage formularies, and create scale that individual actors cannot easily replicate.
Cash pay models, often celebrated as disruptive alternatives, were also viewed with skepticism.
One warning stood out clearly.
“Innovators should be very worried about this move to cash pay.”
If insurance coverage continues to erode, fewer therapies will be reimbursed, fewer patients will be protected, and long term innovation becomes harder to sustain.
Pandemics, vaccines, and the trust problem
When the discussion turned to pandemics and vaccines, the barrier was no longer scientific speed, but public trust.
Manufacturing capacity, supply chains, and rapid response infrastructure still matter, but access increasingly depends on whether people believe the system acting on their behalf.
One speaker captured the challenge succinctly.
“We now have generations who’ve never seen these diseases, and that combined with misinformation fuels hesitancy.”
The return of diseases like measles and polio is not a failure of science, but a failure of sustained communication and trust building. Fixing that requires long term engagement, not reactive messaging when crises emerge.
What this means for founders and builders
The most important message from the panel was not pessimistic. It was practical.
There is no single fix for healthcare access. No single business model, policy lever, or technology will solve it alone.
Progress will come from doing the harder, less glamorous work early. From designing products that fit real payment systems rather than idealized ones. From thinking about access before approval instead of after launch. From using technology to remove friction rather than adding features. From matching solutions to specific populations instead of forcing one model everywhere. And from treating trust and communication as core parts of the product, not external concerns.
Healthcare does not fail because innovation is slow.
It fails because the systems around innovation do not always let it through.
That is not just a policy problem. It is a design problem. And it is one that founders can, and should, help change.
Founder’s note
What stood out to me in this conversation was how often access is treated as an afterthought, something to be addressed once the science works and the product ships. But access is not a downstream problem. It is a design constraint from day one.
If you are building in healthcare, the real question is not just whether your solution works, but who it works for, who pays for it, and who is left out if incentives shift. Those answers shape outcomes far more than any pitch deck metric.
Between Talks exists to surface these conversations early, before decisions harden into systems that are difficult to undo. If we want innovation to matter, we have to design for reality, not just possibility.
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