In 2024, UnitedHealth Group — the largest health insurer in the United States — generated $371 billion in revenue and $22 billion in profit. In the same year, its subsidiary Optum processed 104 million prior authorization requests, rejecting a substantial portion. Americans spent more time fighting for coverage than receiving care. The company's CEO was murdered outside a Manhattan hotel, and the public reaction was not horror. It was something closer to recognition.

That reaction was not random violence producing random sympathy. It was the visible surface of a structural rage that has been building for decades. Americans intuitively understand that they are not patients in this system. They are revenue streams.

The Economics of Sickness

Fee-for-service medicine pays for activity, not outcomes. Every visit, every test, every procedure, every prescription generates revenue. Health generates nothing. The economic logic is merciless: a patient managed on five chronic medications for 30 years is worth more than a patient cured in one visit. A patient who sees 12 specialists is worth more than a patient whose generalist solves the problem. A patient whose condition is managed is worth more than a patient whose condition is resolved.

This is not a cynical interpretation. It is a literal description of how the revenue model works.

Where Your Healthcare Dollar Goes
Administration & billing34¢
Pharmaceutical companies~15¢
Insurance company overhead & profit~12¢
Hospital facility & equipment costs~20¢
Physician compensation~8¢
Prevention & public health~3¢

Three cents. Three cents of every healthcare dollar goes to keeping you from getting sick in the first place. In a system where 70–80% of chronic disease burden is driven by lifestyle and environmental factors. The misallocation is not an oversight. It is the system working as designed.

The Intermediation Web

Between you and your doctor stands a web of intermediaries, each extracting value without creating health. Your employer chose your insurance plan based on cost, not quality. Your insurer negotiated rates with providers based on volume, not outcomes. A pharmacy benefit manager — a company most patients have never heard of — determines which medications you can access and at what price, negotiating rebates from pharmaceutical companies that it may or may not pass through to you. A prior authorization department staffed by algorithms and low-wage reviewers decides whether your doctor's clinical judgment will be honored.

Each intermediary has a business model. None of those business models depend on you getting healthier.

The Complex Patient as Financial Liability

Here is the cruelest structural feature: the patients who need the system most are the ones the system is least incentivized to serve. A patient with a complex, multi-system condition — someone with Ehlers-Danlos Syndrome, mast cell activation, dysautonomia, and a post-viral inflammatory cascade — requires extensive time, cross-specialty synthesis, and creative problem-solving. In a fee-for-service system, this patient consumes far more resources than their reimbursement covers. They are a financial loss.

When I was navigating my own diagnosis across three hospital systems, I noticed something that took me a while to name: the resistance I encountered wasn't personal. It was economic. Every test I advocated for — the sleep study, the genetic panel, the immunological workup — was a test that didn't originate from the referring specialist's silo. It didn't fit their billing code. It didn't serve their revenue model. The system wasn't resisting because my doctors were incompetent. It was resisting because I was asking the architecture to do something it was not built to do. — Jen Berry

The GLP-1 Precedent

And then there's the signal that may break the entire model. GLP-1 agonists — Ozempic, Wegovy, Mounjaro — are demonstrating that prevention economics actually work. Patients on these drugs are showing reduced cardiovascular events, reduced kidney disease progression, reduced healthcare utilization across multiple organ systems. The downstream savings are enormous. But the drugs cost $1,000+ per month, and insurers are fighting coverage because the savings accrue over years while the costs are immediate.

This single class of drugs has exposed the fundamental contradiction in the system: the entity paying for care is not the entity that benefits from prevention. Employers switch insurers. Patients change plans. The insurer who pays for Wegovy today may not be the insurer who avoids the $50,000 hospitalization in ten years. The incentive to invest in health is structurally severed from the incentive to pay for it.

What the Inversion Looks Like

The alternative is not a mystery. It has been demonstrated in every system that has moved toward capitated, outcomes-based payment. When you pay a fixed amount per patient per year and reward keeping them healthy, the entire system reorients. Prevention becomes profitable. Complex patients get more resources, not fewer, because their capitation is higher. Unnecessary procedures disappear because they cost the provider, not the patient. Administrative overhead collapses because there is nothing to bill per-service.

Kaiser Permanente, ChenMed, Iora Health, and Pearl Health's network of value-based primary care providers have all demonstrated this at varying scales. Singapore's Medisave system has demonstrated it nationally. The evidence is not ambiguous. When you pay for health instead of activity, the system produces health instead of activity.

You are not a patient. You are a revenue stream. Every actor in the system — the insurer, the PBM, the hospital, the specialist, the billing coder — has a financial model that depends on your continued engagement with the system, not your exit from it. The only actor whose financial interest aligns with your health is the one who gets paid to keep you healthy.

That actor barely exists in the current architecture. Building it is the investment opportunity of the next decade.