To A.G. Breitenstein, primary care is like the general store owner on the prairie: They try to be all things to all people. But it's a model that Breitenstein sees as outdated in today's world, where health care doesn't need to be one size fits all: When it is, it's often to the detriment of communities. Instead, she wants to build a health care solution that's bespoke for the queer and trans community, an area that is underserved and often actively discriminated against by the current health care system.
"I think this is the beginning of a wave of very specific companies that need to meet people and patients where they are in their lives — based on who they are, where they come from, what their experiences are — as opposed to the traditional primary care model, which treats all people as the same," Breiteinstein said.
It's why she built Folx Health, a new health care company designed for the queer and trans community. Breitenstein started her career as a lawyer for LGBTQ youth and then worked in health care as an entrepreneur and investor. But it was her own experience and countless stories from others that made her realize that a lot of the health care system today isn't set up to adequately address the needs of the queer and trans community. "If you start talking to people, over and above the question of just outright hostility and discrimination, we heard countless stories of lesbians going to the doctor and saying, 'You know, I'm thinking about doing at-home insemination,' and their doctor just being like, 'That's cool. I'll try to find a website for you, but I have no idea how to do that,'" Breitenstein said.
Her solution is starting with a direct-to-consumer model that will allow Folx members to sign up for services like hormone replacement therapy or STI testing. And unlike a lot of DTC companies, such as Hims & Hers or birth control company Nurx, which are more focused on selling products, Folx will help provide the clinical care so that its members are meeting virtually with doctors who are specialized in the needs of the queer and trans community.
After raising a $4.4 million seed round from Define Ventures, Bessemer and Polaris Partners, Folx is launching on Thursday to begin accepting members in six states, before rolling out nationally early next year.
Protocol talked to Breitenstein about why she is building Folx, what it's been like building a new health care company in the pandemic and how a Biden presidency could change things.
The conversation has been lightly edited for length and clarity.
2020 has been a huge year for health care due to the pandemic. So why launch a health care company now, and one that's specifically focused on the LGBTQ community?
There are so many ways in which I think about this as the company that I was always supposed to build. I'm only sort of coming to grips with that now, but I started my career — and I will spare you most of the once upon a time — as a lawyer working with queer and trans kids, and that actually kicked off my desire to get into the whole world of how can we fix health care. So I went to public health school; did some startups and big data analytics, hoping that if we knew better, we'd do better; and then did some investing in health care. The thing that really intrigued me about direct-to-consumer was reestablishing the patient's control of the whole experience and the relationship with the health care system. So much of what happens for folks when they encounter health care is having to deal with insurance and deal with what their employer will cover, and it's just a lot of hand-to-hand combat with the system.
The idea for Folx was really this idea that a lot of us are alienated from the health care system because, for a lot of folks, there's a huge amount of discrimination. About half of the community experiences some sort of act of discrimination, and 7% of cisgender queer folks and 22% of trans folks are actively assaulted in health care settings so [there's] deep, deep alienation from the system. Building a direct-to-consumer platform just made all the sense. It also made sense in terms of accessibility for populations that some of whom live in big city centers, but a lot of the queer and trans community doesn't live in those big cities. Building a virtual platform was really a solution around accessibility and affordability in terms of being able to scale clinical resources and access to the community.
Then COVID hit right literally as we were raising the seed round, and all the reasons we were building it virtually just became 100 times more salient. In some ways, COVID has really accelerated what we knew to be a trend well before COVID hit, which is that care was going to move online because we're getting everything else through our phone, and with some clever thinking, we can make health care super high quality and accessible through virtual means.
So when you went out to raise the seed round, what was the reaction like from investors?
I was very, very lucky in the sense that having been an investor for some years and a previous entrepreneur, I had very deep relationships in the venture community before I went out. I think people were actually very receptive to the idea in the sense that this new model of specialization was becoming very vogue at the time. It still is. That said, I think people didn't have a clear sense of what are the specifics of the experience, what is [it] really like? Is it just we should ask the right couple of questions or not assume when we do a health history or a sex history that you're sleeping with somebody of the opposite sex?
Those are the easy bits. It really took some time to explain the whole of the experience to folks: What does it mean to be deadnamed? What does it mean to be misgendered? What does it mean to go to the gynecologist as a trans man? How does having to explain your new biology work for somebody who's never worked with a trans patient before and now suddenly has one because one of their long-standing patients transitioned?
Those are all questions that I think people just didn't think about, so people were receptive but they just didn't know. They didn't know that most of the trans population gets their drugs through international pharmacies online that are not legal because that's the easiest way to get it, and it's more accessible and it's cheaper. People just didn't have the awareness, so it was a lot of work to bring that up.
Hormone replacement therapy is among Folx's focus areas. Image: Folx
It's interesting because I think that's the first instinct a lot of people have: It's like, why is there even a need for a separate health care system or platform for this community?
It's a huge question, but if you start talking to people, we heard countless stories of lesbians going to the doctor and saying, "I'm thinking about doing at-home insemination" and their doctor just being like, "That's cool. I'll try to find a website for you, but I have no idea how to do that," or a gay man going in and "I asked my doctor about PrEP and they're like, well you're in a monogamous relationship, like, why would you want PrEP?"
It's the shaming, like the "You're married. Why would you want birth control, little lady?" genre of question that women have been dealing with. Or a trans man wanting to get birth control because while they are trans, they may be sexually active with men and testosterone doesn't necessarily prevent pregnancy.
So a lot of both biological and medical specificity is completely unaddressed in the medical education system today. There's multiple layers of barriers between queer and trans persons and good health care on the other side.
So where does Folx step in? What are you building that will start to address some of these needs?
The first thing is to get super focused. We're not going out as a full queer and trans primary care service. We're focused on building very specific offerings in in three domains: identity, sex and family. So we think about [hormone replacement therapy], we think about PrEP, HIV care, STI testing, creation of family — things that are very focused on the specifically queer experiences.
So we're starting with a very carefully curated experience around those sort of platform pillar areas, and then we will layer in the care in between that is more traditional to up to a primary care — things like mental health and more basic care — but the idea is by starting in these areas that are least well-served by the rest of the health care system, we can really build something which is compelling and unique and necessary for every person in this community and really distinguish ourselves. And then start to fill in the pieces and gaps so that we become a more fulsome offering.
When I was looking at your website, it kind of reminded me a bit of Hims & Hers, but obviously oriented with very different products for the queer and trans community. Why take the direct-to-consumer approach instead of going the primary care approach?
DTC gives us the freedom and the latitude to really do stuff that would not be your typical model that you would take to a payer for purposes of getting contracts. But more [than] that, I think it was to build a platform that had a single constituency of focus, and that was the queer and trans community. The thing as a health care entrepreneur and as an investor for my entire career that was very frustrating to me was every single product that was built, whether it's a primary care offering or it's a technology, always has to serve one group of people and try to sell to another.
So even if you're a primary care platform, and suppose we had done a digital primary care platform, we'd have to build that platform for our patients, but we'd have to try to go sell it to the insurance companies.
Second, and perhaps even more importantly, we can do it and are doing it with price points that typically sit below the average copay or deductible. So for us, that was important because if we went in and busted our heads open, doing the typical insurance route with half the country having a copay or deductible of $2,400 or $3,200, we'd end up back in the same place, but just bloodier for it.
The third thing was that one-to-one, direct relationship with what we call the member, not patients, paying us for their services is an extremely clarifying relationship in terms of whose interests you serve. We really wanted more than anything to reestablish control of one's body and one's health care through just a very direct relationship.
By freeing yourself from those insurance markets, are you concerned about cutting out or reducing accessibility? You are still trying to have a lower price point, but there are certainly people who would prefer the insurance route.
We're not trying to be all things to all people. We recognize that we're making a choice and we recognize that there are folks that may not be able to jump in at this level. Again, even people who are insured today, the average millennial today spends about $400 to $600 a year out of pocket on health care, so even if we went the insurance route, we would not eliminate the fact that there will always be a cost barrier until we have [a] 100% universal health care system. So, we weren't going to solve the problem by going the insurance route.
That said, one of the ambitions we do have over time is to develop our own sort of insurance product. Having worked in a big insurance entity, I think there's some really interesting models out there for very innovative offerings that would be specific to the community because you also have to remember: A lot of insurance has a heteronormative and cisnormative structure built into it so a lot of the services that our community wants and needs the most aren't even covered by typical insurance.
What's an example of that?
Gender reassignment surgery is often not covered. Reciprocal IVF for family creation, often not covered. Some of the core things that define needs in our community are not covered because they're not part of the heteronormative coverage plans that most employers purchase on behalf of their employees.
When people are signing up to become members of Folx, what are they actually getting? I saw on your website that prices are starting at $59 a month.
So you made the analogy with Hims & Hers — Hims & Hers and other companies like that are extremely product focused. What we're offering is both the product and the clinical offering.
Take HRT as an example. For folks starting new on HRT, it's not about just the hormones. What we're providing is both a foundation of anytime access to a clinical team, quarterly visits online with folks to be able to do check-ins, tighter dosing, checking in on what are your biological goals or physical goals that you're trying to achieve. So it's all the clinical support that you would typically get with a regular relationship with a doctor but with far more accessibility. People are driving two to three hours to go see a doctor, so it's turning that all into a virtual experience and being able to reach out to your doctor anytime and get that support in addition to home delivered medications and home delivered labs.
For a lot of folks, just being able to do the entire process in the convenience and safety of their home and not have to go deal with looks, deal with being deadnamed at the pharmacy and generally interacting with a system that can be dangerous and hostile at certain times based on where a person lives and where they are in the process.
Folx members will be able to sign up for services like hormone replacement therapy or STI testing. Image: Folx
What keeps you up at night these days then when trying to build a company in the middle of a pandemic?
I don't worry about folks wanting to access care in this way. I think we've all seen, especially during COVID, a massive change in people's understanding of what is capable on a telehealth platform.
I do worry about the world of regulation. Everybody's like, "Wow, it must be really easy to license your doctors. COVID must have made that really easy." And it's like, "Oh, you have no idea how hard it still is and how hard it is to bring great clinical care to people in very rural areas."
The thing that I worry about the most is how we can adapt this regulatory infrastructure which is really very antiquated and built on a face-to-face, nonvirtual model. We're under a public health exemption for a lot of care that was not really allowed to be done virtually. The regulations have a long way to go to catch up so one of the big things that I worry about is the whole idea of getting efficient, effective care online is going to take a massive step back after the public health emergency because we don't have a regulatory infrastructure in place in this country to really support a change that's already actually happened.
Do you think a Biden presidency is good or bad for this?
I hope it's good. Just knowing some of the folks that he's starting to bring into the fold to discuss what the future of health care is going to be, I'm very encouraged. And I think there's an openness and a willingness, specifically around and care quite frankly for the health of the queer and trans community, which I think is going to be a huge help for us. We're not going to have to hide, which is great. We're not going to deal with a completely hostile administration. So, we're very hopeful. That said, he's got a lot to do, so I hope we rank highly on the list of priorities, but I can imagine that list of priorities being exceptionally long.
You said at the beginning of the interview that this is the company you felt like you've been building up to your whole life. I'm curious what it feels like to finally be on the edge of launching it and having this opportunity to improve access for the queer and trans community to health care.
I think I am actually officially old now. [Laughs.] There might have been a point in my life where I would have said, "That's terrifying! We're at the precipice. It's so scary!" But I've actually gotten to a place where I'm old enough to be like, it's exciting. I'm just delighted that we're here.
I believe this is going to be massively successful, but the world can change in a moment's notice, as we all have experienced over the last year. I couldn't be more excited, but I'm also fully ready for anything that comes our way. And I think that's ultimately healthy, because if you attach your entire personhood to a thing outside yourself, you're usually setting yourself up for inevitable heartbreak and disappointment. That said, we have this unbelievable team that is just so fiercely passionate about building this. We've had our first few members on the platform over the last few weeks, and it's just been so exciting to see what the totally different experience can be for them. That's been immensely inspiring, so I just focus on that, and that keeps me mentally healthy.
