The North Carolina State Health Plan turnaround offers a compelling case study for what happens when a state leverages the full set of managed care and benefit design tools available to them. Vice Chairman Brian Miller joins to share his perspective on the philosophy behind the plan's member-first approach and what it suggests for healthcare affordability more broadly.

Brian walks through the principles guiding the turnaround: income-adjusted premiums modeled on Medicare, benefit design that avoids penalizing members with chronic conditions, and a preferred provider strategy that uses the plan's purchasing volume to steer members toward better value. He emphasizes that these tools have existed for decades but have not been applied deliberately and with the member's financial interest as the north star.

The conversation also covers drug affordability, where Brian makes the case that FDA biosimilar regulation is a more effective and underappreciated lever than payment policy. Updating the pathway could make biologics cheap the same way generics made small molecules cheap, without undermining incentives for innovation.

The episode closes on the MA versus original Medicare cost debate. Brian's framework: the answer depends on which of three lenses you use, most people pick the one that gives them the answer they want, and the policy conversation would be better served by using all three.

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Natalie Davis, CEO of United States of Care joins to discuss the organization’s latest polling on healthcare affordability and what it reveals about voter sentiment heading into the next election cycle.

Drawing from research across more than 30,000 Americans, Natalie explains why affordability consistently emerges as the public’s top healthcare concern—not just because of medical bills, but because of the emotional stress, delayed care, and distrust the system creates. She walks through the policy solutions voters support most strongly, including prescription drug affordability, price transparency, site-neutral payments, and anti-competitive merger scrutiny.

The conversation also explores the growing erosion of trust in healthcare institutions and the broader public backlash against a system increasingly perceived as prioritizing profits over patients. Natalie discusses why affordability reform is gaining traction in conservative states, how fragmented incentives make systemic change difficult, and why many organizations no longer have the leverage to independently reduce costs even when they want to. They also touch on AI in healthcare, where patients are simultaneously optimistic and deeply skeptical, with transparency and trust emerging as the key factors shaping adoption.

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Bryan Roberts from Venrock joins to discuss Eli Lilly's acquisition of Kelonia, a gene therapy company Venrock seeded in 2020, for up to $7 billion.

Bryan walks through the original investment thesis: autologous ex vivo CAR-T therapy was producing remarkable efficacy in late-stage multiple myeloma, but everything else about the model was broken: six to seven week processing times, $220,000 cost of goods, and delivery restricted to academic medical centers. The bet was that Kelonia's in vivo platform, developed out of MIT and CNRS in France, could preserve the efficacy while eliminating the rest.

He describes the path to exit as anything but linear. The 2022 biotech financing freeze hit preclinical cell and gene therapy companies especially hard. Kelonia survived through pharma partnership deals with Astellas and J&J that funded operations without giving up the lead program, and by staying focused on getting to clinical data, which they achieved mid-2025.

The conversation closes with Bryan's honest read on the cell and gene therapy landscape: the $2M+ commercial launches have largely failed, the path forward is pricing in the $300-400K range, and the infrastructure required to deliver these therapies broadly is at least a decade away from where it needs to be.

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