Apr 13, 2018 · 28m · y-combinator
Anne Wojcicki : How to Build the Future · Y Combinator
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In this Y Combinator interview hosted by Sam Altman, 23andMe co-founder and CEO Anne Wojcicki shares the vision behind direct-to-consumer genetics, discussing how personal data ownership, scientific rigor, and persistent execution can transform modern healthcare.
How this conversation actually went
Every chapter scored 0–10 on four independent dynamics. Hover any point for the reasoning behind the score. How this is scored →
The partners as informed peer 3.3 Guest teaching 2.9 Guest disagreement 0.8 The partners pushing back 0.3
speaking balance: gold is the partners, purple is the guest (3 minute bins)
Sharpest disagreement ▶ 26:16 Reframing universal health advice
Wojcicki directly counters Altman's assumption that general lifestyle rules apply equally to everyone, pointing out wide biological variance where some individuals tolerate high sugar or smoke without disease.
Hardest push from the partners ▶ 26:02 Pushing on common sense health discoveriesAltman presses Wojcicki on whether 23andMe has discovered non-obvious general health trends, noting that basic advice like avoiding soda is already common knowledge.
Biggest teaching moment ▶ 4:36 1969 JAMA study on physician paternalismWojcicki provides historical perspective on medical paternalism by citing a 1969 JAMA study where over 90% of physicians surveyed admitted they would not tell a patient their cancer diagnosis.
The partners hold their own ▶ 16:44 Net output framework on toxic hiresAltman demonstrates management expertise by sharing his framework for evaluating high-performing but toxic employees based on their net negative impact on the broader organization.
the scores for every segment, with the reasoning behind each
| Chapter | Topic | The partners as informed peer | Guest teaching | Guest disagreement | The partners pushing back | Why |
|---|---|---|---|---|---|---|
| Founding Story of 23andMe & Healthcare Vision | 2 | 3 | 1 | 0 | Altman opens with standard introductory questions. Wojcicki provides a detailed background on how Wall Street taught her that the healthcare system is structured to monetize illness rather than incentivize health. | |
| Designing Direct-to-Consumer Healthcare & Overcoming Systemic Resistance | 4 | 5 | 1 | 0 | Altman quotes Charlie Munger on incentives and recalls industry backlash at 23andMe's launch. Wojcicki schools the discussion with medical history, citing early resistance to home pregnancy tests and a 1969 JAMA study on cancer disclosures. | |
| Fixing Healthcare Incentives & Individual Responsibility | 3 | 3 | 1 | 0 | Altman asks how to fix systemic incentives, and Wojcicki outlines single-payer dynamics and individual responsibility. Altman notes the intersection of genetics and crowdsourcing. | |
| Early Company Launch, Navigating the 'Trough of Sorrow,' and Building Scientific Credibili | 3 | 2 | 0 | 0 | Altman inquires about managing the 'trough of sorrow' post-launch. Wojcicki explains how slow sales led her to do hundreds of talks and publish peer-reviewed papers to build scientific credibility. | |
| Critical Early Decisions & Hiring for Humility | 4 | 2 | 0 | 0 | Wojcicki describes hiring early scientists with humility over ego. Altman contributes his own organizational framework regarding evaluating a hire's net output on the entire team. | |
| Navigating FDA Regulation & Working with Government Agencies | 3 | 3 | 1 | 0 | Altman asks about operating in a heavily regulated domain. Wojcicki candidly reflects on how 23andMe had to shift away from Silicon Valley argumentative habits to respecting the FDA's public safety mandate. | |
| Long-Term Vision, Strategic Persistence, and Compound Growth | 3 | 1 | 0 | 0 | Altman and Wojcicki align on the power of strategic persistence, comparing the slow build of biotech impact to compound growth. | |
| The Next Decade: Large Datasets, Intervention Studies, and Longevity Vision | 4 | 4 | 2 | 2 | Altman questions whether health insights go beyond obvious rules like avoiding soda. Wojcicki counters by explaining genetic variability in metabolism and highlights large-scale intervention studies. |
Statements from this episode (15)
Wojcicki: Healthcare Industry Monetizes Illness Rather Than Prevention
“At the end of the day, healthcare is an amazing business that really effectively monetizes illness, and I used to always say, you know, if I successfully get you to never be diabetic, No one makes money. But if you do become diabetic, there's all kinds of ways…”
Wojcicki: The Healthcare System Cannot Be Changed from Within
“You can't change the system from within. So we gotta do something more radical from outside.”
Wojcicki: Healthcare patients lack decision power because they aren't the direct payer
“The main thing in healthcare is that you don't actually ever have a voice. Like, you don't, like, you don't actually, because you're not the payer in healthcare, like, you the individual, you don't actually make decisions. It's, you know, your insurance compan…”
Wojcicki: 1969 JAMA study found 90% of doctors withheld cancer diagnoses
“One of my favorite papers is there's this JAMA paper, the Journal of American Medical Association from 1969, I think, where they asked doctors, would you tell your patients that they have cancer if they had a cancer diagnosis? And over 90% of them said no.”
Wojcicki: Medicine is practiced as art, causing conflicting cancer treatment recommendations
“Part of what people don't necessarily always understand is that the practice of medicine is, is an art. Like, you can go, the reason why you can go to five different physicians and get five different ways of you know, treating cancer is because there's the pra…”
Wojcicki: Universal Healthcare Payment System Will Never Happen in US
“I think the reality is what needs to happen is never going to happen. Which is like you have a universal payment system.”
Wojcicki: Single-payer systems are structurally incentivized to maintain long-term health
“And I think for a single-payer healthcare system, or like a country they care about actually trying to keep you healthy for as long as possible.”
Altman: Transformative startups emerge from intersecting trends identified early
“I've noticed that many of the most transformative companies come because the founder sees some, like an intersection of two pretty different, but really important trends a few years before everybody else does.”
Wojcicki: 23andMe Post-Launch Sales Dropped to 15 to 25 Kits Daily
“And we were probably selling 20 to, you know, 15 to 25 kits a day.”
Wojcicki: Science Startups Must Publish Peer-Reviewed Data to Build Credibility
“It's one thing I always advise science companies is you can't speak, like, I can't just tell you, like, oh, we're great. We have great science. Like, no one, like, no one believes that. So what you need to do is you need to publish. Like, you put, like, I neve…”
Altman: Screwing up the first five to seven hires is almost fatal
“We, we've noticed that it is almost impossible to, you can make a lot of mistakes as a company, but if you screw up the first five, seven hires, it's almost impossible to get through that.”
Altman: Evaluate employees by net organizational output, not isolated individual productivity
“And the framework that I finally figured out is it's, you have to look at the net output that a person has on the organization as a whole. And even if they do a lot themselves, if they make everybody else miserable.”
Wojcicki: Startups dealing with regulators must prove claims with data, not trust
“The onus is on us a little bit to explain how we're doing it, how that works, and the way they speak, just like I mentioned about scientists, is they speak in data. Like, you can't just say, like, oh, no, no, no. Like, trust me. Like, I'm the good guy. Right. …”
Wojcicki: 23andMe's 2007 Series A OKRs match its 2018 operational goals
“Our Series A documents and our OKRs from 2007 are remarkably similar to what they are today.”
Wojcicki: 23andMe ran a 70,000-person genetic weight loss study
“So we did our first one on weight loss. So we had 70,000 people doing, you know, a six arm weight loss study. So that's the first time we're doing it in that kind of scale, specifically to see based on your DNA, are there differences in weight loss?”