How heath tech startups are responding to the post-Roe world

Danny Crichton:
I think that would be great. All right, let's do one more shot. Someone's visiting here. Who the hell's that?

Hello and welcome to Securities, a podcast and newsletter devoted to science, technology, finance, and the human condition. I'm your host, Danny Crichton. And today we're talking about the post Roe world. Tomorrow it'll be 30 days since the Supreme Court announced in the Dobbs v. Jackson Women's Health Organization that there is no constitutional basis to the right to abortion, overthrowing several decades of court president. And that has huge implications for tech start-ups, particularly those focused on women's health. Instead of operating in a nationwide environment with a single set of laws, these startups are now going to operate across 50 states with 50 different state laws. And that has huge implications for things like privacy, data management and governance, who gets to decide who gets women's health and who doesn't as well as other issues.

And so I asked my partner, Deena Shakir, to bring together a panel of guests to talk more about how startups are responding to this decision, particularly now that there's been a little bit of time to digest the decision and figure out more about what's going on. And so we've got three folks today. First Paxton Maeder-York, the founder and CEO of Alife Health. Second, we have Dr. Neel Shah, the chief medical Officer of Maven Clinic, and who is also an assistant professor of obstetrics and gynecology and reproductive biology at Harvard Medical School. And finally and third, we have Halle Tecco, who is among many other things the head of women's health for Everly Health.

Deena, take it away.

Deena Shakir:
I just want to start with a quick kind of lay of the land from each of your purchase in terms of what the last 30 days have been like and what you feel the next 30 days and 30 years will look like for the future of women's health. I want to start with the view from the practitioner, from the provider who is in this case, you, Dr. Neel Shah.

Neel Shah:
Last 30 days have been wrenching, I mean for all of us. I mean, as Maven Clinic is a women's health company and we take care of people all over the country and we've seen this coming for a long time now. And yet, even though we expected the decision, it was still a gut punch and it was still disorienting because of the fact that I think there's the letter of the law and then there's how people choose to interpret it. So I mean, I think first and foremost as a doctor, what I feel is that the law of the land in ways that are really hard to wrap my mind around orthogonal or even against the moral duties of providers. Just this week I took care of somebody who we discovered an ectopic pregnancy about four weeks in before most people would even know they're pregnant.

In tandem, I had a colleague in a different state who had to sit on the exact same case and watch somebody bleed until it was deemed life-threatening by lawyers, not by clinicians. I was conscious of the fact that if I were to consult with that doctor, we're in a state of a play right now where as a doctor in Massachusetts, there's an executive order from my governor that is a non extradition policy that says that somebody can charge me with a crime in a different state, but my state is not to cooperate with theirs. I mean, these are truly, truly what is the word to put to that? Wrenching, disorienting, painful times. I guess what I'll also say just to from the practitioner's point of view, and I think that Halle and Paxton will probably agree with this, it's impossible to take care of somebody who's either pregnant, trying to become pregnant or pre-contemplative about being pregnant without encountering people who ultimately are going to be in situations where their pregnancy is medically dangerous, psychologically excruciating or otherwise undesired. And that is why abortion is healthcare.

Deena Shakir:
And if there ever were to be a title for this, I think abortion as healthcare, would be just that the implications are far-reaching. I think that's the great segue into talking about the fertility angle, which is one that has not been necessarily as top of mind. And we're really just beginning to understand these trigger laws that have gone into a factor that will soon, and many of them include language that defines life as beginning at fertilization. I think providers, patients, everyone is trying to figure out what that means in the context of fertility care. And it's being evaluated on a case by case basis. The American Society of Reproductive Medicine has given us some warnings on states that we should be keeping an eye on and this idea of personhood bills. Paxton, can you tell us a little bit about how as a company that's building technology to help make fertility care more efficient and effective and equitable, how you're thinking about the impact on the future of fertility care?

Paxton Maeder-York:
The last 30 days for us have been obviously very uncertain, very heartbreaking. We're still watching it unfold how this new world that we're living in is going to impact the areas like IVF. We just don't know what the end result's going to be, but we do know that there is going to be some ramifications here. And we are seeing clinics that are starting to move their embryos out of state to help retain the optionality for those patients. But I think it's still very early days to see how this cascades through the different areas of medicine.

Deena Shakir:
Halle, you, in addition to leading the women's health efforts for Everly Health, are an active investor and advisor to a number of companies across the spectrum of healthcare. You have a really interesting, I think, purview into where some of the greatest challenges are. I'd love to hear a little bit about as we navigate everything from fertility care to racial disparities in care, where are you seeing some hope here? Where and how can some of these companies that we're investing in move the needle in addressing these real serious life-threatening situations as a result of this overturning?

Halle Tecco:
Gosh, I mean, it's just been a very intense month and we're now kind of getting to the point where it's like, "okay, let's let this work begin." And what I'm seeing that makes me most hopeful is collaboration from so many different parties, from patients who have been quite vocal, women who have been quite vocal about how we feel about our rights being stripped away to literally every medical care organization, the AMA, ACOG, ASRM are all aligned. And so it feels like we have critical mass and we know we do, right? We know that most Americans support abortion. I think that we're kind of now feeling like, "Okay, let this work begin."

And so I'm also on the board of RESOLVE, which is the largest infertility nonprofit that has been fighting personhood bills for 30 years. And in our back pocket this whole time has been Roe. And so we've been able to not allow the personhood bills to win because they wouldn't stand up in federal court. And without Roe we don't have those protections. And so it's been a scary time for the infertility world to see what's potentially going to happen there.

But I don't want to just fight for the wealthy infertile people like myself. If an embryo or fertilized egg is a human to a state rather that is a wanted baby through IVF or that is an unplanned pregnancy through other means, we should treat everybody the same. I don't want IVF to be a carve out in states. I don't want to see that because I think that it gives a pass to those who are wealthy and able to afford IVF to focus on their problems while leaving everyone else behind. And we know that people who do IVF are disproportionately white and wealthy and we know people who need abortions are disproportionately people of color and disproportionately poor.

So I think this is our chance to all work together for common human rights amongst, for every American, for every woman, every family, and come together whether it's because we believe that women should be able to terminate for medical reasons, whether we believe that they should be able to terminate for any reason. It's no one's business for contraception access, for fertility treatments. Whatever kind of guides our own north star, we can at least all gather together and determine that abortion is medical care that needs to remain between a patient and a medical provider and no one else.

Deena Shakir:
It's so unfortunate that it seems like there needs to be this inherent trade off. I know this has been something that has been top of mind for a lot of fertility care providers now who are faced with this dilemma. What if they had to make a choice in protecting IVF at the expense of some of these other laws? And part of the reason I have the three of you here around the table and why we're also investors in everything you're doing is because this idea of equity and health equity is so core to everything you're working on. And for Alife, Paxton, perhaps you could share a bit more about how you're thinking about everything from how you're building the data set to how you're thinking about care delivery. Paxton, could you share a bit more about how you're thinking about health equity in the context of this decision and the work that you're doing with Alife?

Paxton Maeder-York:
Obviously, infertility impacts many people across demographics, ancestries, socioeconomic layers. And unfortunately what we see in the historical data is that underrepresented groups have worse outcomes on average relative to other demographics. A lot of what we're focused on in Alife is really trying to help support improved access through better education, lowering costs, and really trying to build tools that enable optimized outcomes and personalized precision treatment for everybody regardless of their ancestry. What we've done to enable that is build relationships and amassed a huge and critically diverse data set that we leverage to pull out these data driven insights to empower clinicians and patients to make what we believe to be the optimal treatment recommendations and improve access and improve outcomes for those individuals.

I think when it comes to Roe v. Wade, this type of work is even more important, especially for individuals that are in these different geographies or in a lot of cases what's going to happen here is that people that are able to have to travel out of state. It means that the cost of these reproductive care options are only going to increase. On top of that, the clinics that are in more progressive states are going to be overloaded with even more patients. And so building tools and systems like what Alife is building, which is really meant to optimize, improve outcomes, reduced costs, increased clinical efficacy and efficiency are going to become even more important in this post Roe v. Wade world. And we're very grateful that we've been able to gather so much data from all these wide bearing kind of clinical practices and patient populations, because for the first time we're able to pull out these really important correlations that can result in more health equity when it comes to reproductive healthcare.

Deena Shakir:
Neel, you have been an advocate practitioner, a voice for many, many years around addressing the Black maternal health crisis. And this is now a core piece of what Maven is doing as well. What can we do to protect the progress that we've all been fighting for and addressing maternal health for these communities given the clear impact, unfortunately, of this reversal and the fears that are very real about life and death situations and women being put at risk?

Neel Shah:
Sure. I'm going to take this as permission to be professorial for a second. But-

Deena Shakir:
Definitely.

Neel Shah:
... just to level set for a second, an American today is 50% more likely to die in childbirth than her own mother was. That is a really shocking statistic, but it's not one that was well known until relatively recently because you can't fix what you don't see and you can't see what you don't measure. And in the United States of America, we did not systematically track maternal mortality until relatively recently, but now we do. It was actually gumshoe journalism that kind of unearthed this and then the CDC followed and now we're having a national conversation.

It's important, I think, to know that maternal health is sort of a bellwether for the wellbeing of society as a whole. If moms are unwell, society is unwell. And that's why every injustice in society shows up in maternal health, whether it's gender inequity or racial inequity or geographic inequity, especially as you look out across the country in a post Roe world and our states are very uneven when it comes to access. Or generational inequity, which is what Build Back Better and Make America Great Again, are kind of tapping into, is this idea that open opportunity in our country are eroding. And one of the primary leading indicators of this is the wellbeing of moms.

Now, that's across the board on average. But if you're Black in America because anti-Black racism has roots in slavery and is the most severe form of racism, you're Black in America, you're three to four times more likely to die. And again, that's on average. But in cities like New York City, you're actually eight to 12 times more likely to die. And that's because there's a really big difference in what you have proximate access to if you live in Jackson Heights, Queens, where my family is from versus the upper east side of Manhattan. It is a fact across healthcare that the zip code or the neighborhood that you live in has a tremendous impact on your wellbeing in a segregated country that falls along racial lines because historically we've divested from a lot of neighborhoods, particularly historically Black ones.

It's not necessarily that an app is going to fix healthcare or that digital health is a panacea to all of this, but I think the promise of digital health is to change the paradigm where you physically are determines what you have access to. And so part of what we're trying to do at Maven Clinic change that so that if you live in the delta of Mississippi, even if you don't have a lactation consultant or a doula or somebody to give you options counseling on what to do with your pregnancy that's physically close to you, we can provide you with necessary healthcare.

Deena Shakir:
There is so much promise in the health technologies that are out there, and I'm very grateful to you for the work that you're doing, Paxton and Halle, but I think there's also been a lot of discussion recently about the potential peril and especially in the context of privacy. Halle, you had some very helpful, thank you, tweet threads on this topic. So I just wanted to turn to you to help us explain what's fact versus fiction here and what should patients really be thinking about in the context of privacy and in particular with period trackers and some of these other consumer apps?

Halle Tecco:
To be honest, I really hadn't thought much about privacy and period tracking until Roe was repealed and just realizing that the criminal justice system could start using these tools against women, which is really scary. So the fact is most period shopping apps have absolutely no legal obligation to keep your health data secure and private because HIPAA doesn't apply to them. So unfortunately, this exemption means that they can share your health information with whomever they want as long as they're informing you of these privacy policies. "Scroll through quickly and click okay." Most people don't really spend time understanding where their data goes. And so many of them are selling your data to third parties, to advertisers and don't really need to tell you. But we are seeing that some states are signing kind of these data privacy acts. I don't think they're enough. I haven't spent too much time looking into them, but even I was looking into the CCPA, the California one, which attempts to protect residents in California.

But when you look at what companies have to comply, it's businesses that are over 25 million in revenue, have 50,000 customers in that state and who derive 50% of their revenue or more from selling the resident's personal information from that state. So a lot of these period tracking apps are much smaller than that, right? I don't know. Maybe a couple of them are making 20, 30 million, but certainly they aren't meeting that other qualification of having half the revenue from selling data. So I think that we're starting to see women deleting their period checking apps. There's a lot of conversation amongst patients and going back to other methods, which is concerning because for people who are not on birth control, tracking is the second-best option for optimizing for pregnancy or optimizing for not getting pregnant.

The peer tracking apps have been really helpful and I hope that we can figure out a way to have options. I know some companies have come forward saying that they will not release data, but who knows what would happen when they get a warrant from some state? And that's pretty scary. I think we're kind of seeing what's going to happen there and I hope that more states come forward and set up requirements that might be big hurdles for these period trackers, but ultimately we'd be better for the users.

Paxton Maeder-York:
And I just wanted to jump in there because not only does HIPAA protect the patients and their data, it also protects the companies and creates a shield around, "If we're court ordered, we can provide PHI, but we're not obligated to do so." Especially for those period tracking apps, it is scary that they're not under this umbrella, but this is all kind of in the context at odds with what Neel was saying, which is if you can't see something, you can't change it and you can't see it if you don't measure it. And you need data to measure everything.

And so all the power of what we've created across all these organizations that we all work at in these digital health platforms is that we have access to these amazingly rich data sets, allow us to do this foundational work and research to look at disparities and figure out ways that we can combat them with clever data science or other methodologies. And we need to continue to do that, but we also need to recognize that that's privileged and important data that needs to be protected under HIPAA or other types of legal and privacy structures.

Deena Shakir:
Yeah, it's interesting because so many of these apps, a number of them now are actually considered to be digital therapeutics and actually prescribed as birth control. And so how does data privacy come into effect when this is actually a medically acceptable intervention? I don't think any of us know. I was reading this morning about, again, the discussion about bringing hormonal contraception over the counter and what role the FDA will play here and how we think about that. Yeah, and it's hard to believe it's been 30 days, but as we're all coming to, I think there was that initial pain that we all felt and now we're starting to process what this means and how we address it. And as VCs, we kind of need to be optimistic about the world and we're so grateful for all the work the three of you and your companies are doing in addressing this.

I've said that I believe constraints can compel creativity in a lot of ways, but this is a real challenge facing every human, not just every woman of course, but every human on this planet. And it is a challenge each one of you in your roles as leaders in the space are needing to address in the context of patients and providers. As you think about the next 30 days, 30 months and the next 30 years, how are you channeling these concerns into key focus areas and how are you thinking about next steps here?

Halle Tecco:
On Sunday, I wrote an op-ed in STAT News around this potential for over-the-counter birth control. So the first company, HRA Pharma submitted for an application for what would be the first brand to go over the counter, which had me thinking a lot about just how important it is going to be to prevent unplanned pregnancies, which are expensive. And now we don't have as many tools for dealing with them, so how are we going to prevent pregnancies? Now we know that banning abortion does not actually ban abortions. People have abortions whether they're legal or not, but I think if we can make contraception more accessible and affordable, it's like 18 million women that live in contraception deserts and don't have access. The fact that it costs $10,000 for an unplanned pregnancy, whereas birth control is quite affordable and unfortunately not universally covered. There are even people who have health plans that under the ACA need to be covering it.

If you work for a religious employer, they can exempt it and not give you birth control, which is crazy to me. We're supposed to have separation of church and state. Yet you can have a religious employer that says, "Oh, I will not. Your insurance will not." The insurance that you pay for, that you work for cannot cover birth control. So I think we really need to work together across the aisle on tactics that we know. So comprehensive sex ed, I mean we really have to start there. We are continuing to put money in abstinence-only education that we know not only is it ineffective, it's counterproductive. Children who go through abstinence only education are more likely to have an unintended pregnancy. So we need to have comprehensive sex ed that is evidence back that we know that works and we need to have accessible birth control.

And then third, something that I've been thinking a lot about, and there are couple of people exploring this in ventures, but male birth control. The burden of pregnancy is so much on the woman and it always has been physically, emotionally, legally. And if we could really spread that burden a little bit onto the men, sperm is responsible for 100% of unplanned pregnancies. So what can we do? Can we invest more resources into finding birth control for men? I think that would make a big impact on women's health.

Deena Shakir:
Absolutely. Neel?

Neel Shah:
We're a service delivery organization at the end of the day, so that's the lens that I'm looking at this through. And for us, the last 30 days, the next 30 days of foreseeable future, we're very focused on the core of the service that every single person deserves access to, which is knowing what their options are. What we worked very hard to do is to make sure that it was visible within our product to everybody across fertility, general wellness, preconception, maternity, that if they were pregnant and wanted to know what their options were, they could very seamlessly access somebody who could help them and tell them the facts, what is medically recommended. And then in an increasingly complex and evolving landscape, what is legal where, which is a moving target, but really, really important to be able to provide people with that sort of access and clarity. And then to make sure that we're never treating somebody as a uterus, right?

The whole purpose of trying to make healthcare work better for people is to make sure we're wrapping around them with all the other services that they need, whether it's mental health, whether it's travel reimbursement in many cases, especially as people have to increasingly sometimes travel hundreds of miles to access care. So that's our near term focus. In the long term, we're not powerless either. I think part of what galvanized us to move in this direction actually was following the line, the lead of other providers. Several months ago we asked providers on our platform across multiple verticals to raise their hand if they wanted to be part of the solution, if they felt trained and willing to provide this kind of options, counseling in some cases to provide medication. And the overwhelming majority responded affirmatively despite all of the uncertainty, and then really worked with people across the organization from engineers to product to our growth teams and across the board.

The other thing that actually gives me a lot of hope I think forward is that historically corporate America hasn't been excited to jump into hot button political issues. I don't think they're necessarily more excited to do so right now, but they're compelled to. And what I'm seeing is that some of the biggest logos in the United States of America are solutioning alongside us as partners. One of the most exciting things about my job is that we get to work with them to figure out what they're going to do and hopefully point them in the right direction and support them.

Deena Shakir:
Yeah. It has been heartening to see in this sort of purgatory of inaction as we kind of await our fates when it comes to the regulatory environment to see employers and corporates step up and provide care and recognize that this is not just about a niche issue, that this is fundamental to human health, which is fundamental to productivity and the economic implications in near term and long term. I think we're about hitting on time now. Are there any topics that you all wanted to address that we didn't have a chance to talk about?

Halle Tecco:
So many. I think all of us could talk about this all day.

Deena Shakir:
Totally.

Halle Tecco:
I think one thing I've been thinking about is like, will this give women's health kind of be attention that it deserves within venture? So even just last year, women's health made up just 7% of all digital health funding. So as a percentage of overall venture capital funding, quite low. But maybe having these sort of hard conversations and seeing the impact that legislation is having, I'm hoping that more investors will follow investors like you that have been investing for a while in this space, but recognize that it's not just a space where you can see fantastic returns because there is real businesses to be made in women's health, but also one where you can make a genuine impact.

Deena Shakir:
Absolutely. I've actually been asked that question a lot recently. I think to your point, given that we've been doing this for a while, is what are you hearing from other investors. And I think honestly, there are a lot of people who want to do something. Capital deployment is one mechanism for action. There is clearly a need. Human health is not something that goes and comes with economic recessions or regulatory constraints. People will continue to be born, people will continue to die, people will get sick. Some of these regulatory constraints will accelerate some of the getting sick parts of it, which is very unfortunate. And I think we need to do everything we can in our power to address that.

So what you all are doing in your capacities as entrepreneurs and as leaders is one way to do that. And what we can do as investors in helping to support that is not only an incredible means for impact, Halle, you're absolutely right. But as you have said before many times, and as I continue to say, it is a massive opportunity for value creation and for more bullish than ever. And I'm hearing of a lot of people who are coming knocking and want to do more. So I continue to be hopeful and bullish on this space.

Neel Shah:
I need to double click on just the paradox of what you just said for a second because we have the high note that you just ended on. But just on one hand, reproduction is agnostic, right? People will continue to build their families whether they have a safe and dignified way of doing it or not. And yet, historically, societally, we've always treated reproduction as a cost and not as an investment, which is mind-blowing, but that is exactly why building out this category in women's health and driving more investment in innovation is so important right now. That wasn't a line for the podcast. That was just like [inaudible 00:28:21].

Deena Shakir:
It's so good. Neel, you have so many good little sound bites. I just want to take them all and turn them into-

Neel Shah:
No, you said that.