Web Exclusives - Editorial
David B. Nash, MD, MBA
Editor-in-Chief, American Health & Drug Benefits; Founding Dean Emeritus, Jefferson College of Population Health, Philadelphia, PA

Can lightning strike the same place twice? Evidently, because Hemant Taneja and Kevin Maney (plus an additional expert) have done it again! Allow me to explain. In my November 2018 editorial in these pages,1 I reviewed a fascinating book titled Unscaled: How AI and a New Generation of Upstarts Are Creating the Economy of the Future, by Taneja and Maney.2

Now, fast-forward 2 short years later (which seems like a lifetime because of COVID-19), and along with Stephen K. Klasko, MD, MBA, this expanded team has written a fantastic follow-up book titled UnHealthcare: A Manifesto for Health Assurance.3 The authors took chapter 4 from Unscaled and greatly expanded their central thesis; this effort has resulted in this new book UnHealthcare.

Let me give you the book’s punchline upfront, and then I will highlight certain key challenges. The punchline—by applying the unscaled model to healthcare, we can leapfrog past the economies of scale to create “health assurance”—is a totally personalized system, in which healthcare is always on, in a proactive way, to keep you healthy.

Although preventive health is certainly not a new concept, health assurance is driven by key technologies that have been developed over the past decade, such as mobile platforms, social media, cloud computing, artificial intelligence, and robotics.

In UnHealthcare, Taneja and colleagues note, “These technologies make it possible to efficiently and profitably offer personalized products and services at scale—which means every individual can feel like the product or service revolves around him or her.”3

Finally, this unscaled model, using all these tools noted above, raises the following question: “What can I build that makes each individual happy in their individual way?”3 The authors claim that health assurance will give birth to more than 10 to 15 $100-billion companies when the $3 trillion in annual health spending in the United States shrinks.3

This powerful and compelling thesis that “when everyone is happy, spending on healthcare services decreases” creates the so-called “Klasko Conundrum.” As the Chief Executive Officer of Jefferson Health and President of Thomas Jefferson University, Dr Klasko has engineered a 6-year effort to merge 14 hospitals into the largest provider organization in the Philadelphia region. After embracing the “economies of scale,” he is now advocating “unscaling.”

In UnHealthcare, Taneja and colleagues explained this conundrum by stating, “Jefferson had to scale up because the healthcare industry’s shaky economics meant that the only path to survival was merging operations to cut costs and become an essential asset for the community. Steve [Klasko] must manage the difficult task of scaling up Jefferson to survive now, so Jefferson can be in a position to unscale later.”3

So, how exactly does unscaling work? In short, it is all about harnessing the data and turning them into actionable information. According to Taneja and colleagues, “Care will become an always-on proactive way to keep you healthy, as opposed to reactive care once you’re sick.”3 A doctor visit becomes an opportunity for empathetic communication, counseling, and encouragement, which are qualities that are currently in short supply, because of the perverse economic incentives that are currently embedded in our “do more, make more money” system.

The doctor visit also provides an opportunity to address the social determinants of health, such as food insecurity and medication affordability. The doctor visit is also transmogrified into a goal-setting session that is focused on attaining and maintaining health. Sign me up!

The good news, Taneja and colleagues say, is that “today’s unscaling forces allow highly-focused companies to profitably deliver personalized, terrific customer experiences, often giving everyday consumers service that used to cost a fortune.”3

Space limitations preclude a detailed review of companies such as Livongo, Mindstrong, Commure, and others, all of which are recipients of critically important formational capital from the venture capital firm General Catalyst, for which Mr Taneja founded the Silicon Valley operations.

The transition to health assurance will not be easy, because hospitals and insurance companies will likely resist any change in their central status in the system. The core of unscaling—“taking apart the scaled-up, mass-market operations of last century and replacing them with highly-focused, profitable niche offerings that better serve consumers in that segment”3—will be a call to arms by the current powers that are driving the largest industry in the nation.

By mostly eliminating hospitals and insurance companies from health assurance, the authors will likely lose many readers (and supporters) along the way. They seem well-prepared for this challenge as they outline, in some detail, their “10 principles of health assurance policy design,” and an additional set of nearly 16 design principles for new companies that attempt to capture the moral high ground with principles such as “above all, build with empathy.”3

Careful readers will have to decide exactly how these principles, from either list, can be operationalized. There is no question that it will be messy at best.

I admire Taneja, Klasko (and yes, Dr Klasko is indeed the ultimate leader of my own organization), and Maney; their arguments are crisp, concise, and compelling. I envision many challenges to creating health assurance, one of which may be a huge pushback from the powers that are driving the status quo. Health assurance will undoubtedly work for the well-educated middle class and above. It will be daunting to spread this gospel to the millions of Americans who have suffered during the pandemic, including the elderly, the poor, minorities, and the otherwise marginalized people in our society.

UnHealthcare closes with a homework assignment of sorts, based on one’s current role in the healthcare system, including developers, entrepreneurs, innovators, and healthcare professionals. In short, the authors rightfully believe that we all have a role to play in transforming the healthcare system of the future.

I would argue that one major challenge, which is barely touched upon in the book, will be changing the educational and training systems for exactly those healthcare professionals whom the authors call out.

In the final analysis, Taneja, Klasko, and Maney are akin to 3 wizened veterans, from separate theaters of battle. They have all “been there and done that.” By joining forces together, they create a force multiplier, perhaps powerful enough to truly tackle one of our nation’s most pressing problems, which is bridging the gap between health and healthcare delivery in the epoch of COVID-19. We should all listen carefully to what these warriors have to say.

As always, I am interested in your view. You can reach me via e-mail at This email address is being protected from spambots. You need JavaScript enabled to view it..


  1. Nash DB. Unscaling population health. Am Health Drug Benefits. 2018;11(8):394-395.
  2. Taneja H, Maney K. Unscaled: How AI and a New Generation of Upstarts Are Creating the Economy of the Future. New York, NY: PublicAffairs; 2018.
  3. Taneja H, Klasko S, Maney K. UnHealthcare: A Manifesto for Health Assurance. Philadelphia, PA: Thomas Jefferson University Press; 2020.
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