Matthew Zachary
The American health care system works exactly as incentives dictate. That sentence sounds almost boring until you take it to its logical conclusion.
Insurance companies now influence clinical decisions more aggressively than many doctors do. They form hospital integration. They determine the feasibility of starting. This has implications for venture capital allocation. They determine which drugs are commercially successful. They put pressure on physician behavior through reimbursement design. They decide who will have access to diagnosis, rehabilitation, home care, specialty medications, imaging, mental health services, and sometimes whether there is enough time left on Earth for patients to see their children graduate from college.
And anyway, we still spend a ton of time talking about apps.
I have spent nearly 30 years inside this machine as a brain cancer survivor, non-profit founder, media mogul, medical conference producer, policy advocate, and accidental anthropologist of American institutional failure. I watched every corner of my medical appointments change. Precision medicine. Digital therapeutics. Patient participation. AI. Consumerism. Value-based care. Harmonious treatment. Interoperability. voyage. Peripheral listening. Population health. Personalized medicine. Blah blah blah.
Meanwhile, millions of Americans spend their afternoons arguing with Chad, the insurance company guy they’ve never met but who has the power to overpower their oncologists.
At some point we have to admit the obvious. Innovation stopped driving health care years ago. Insurance now drives healthcare.
This realization lies beneath every chapter of my new book, We the Patients: Understanding, Navigating, and Surviving America’s Healthcare Nightmare. I wrote this because after decades inside the system, I finally understood something was uncomfortable. Americans feel upset about health care costs, wait times, medical debt, or inaccessible care. Yes. But underneath there is a deeper anger that most people find difficult to express.
People instinctively understand that someone they did not elect now controls a huge part of their lives at their most vulnerable moments.
That’s what changes a country.
Healthcare executives still talk about “patient experience” as if someone discovered the FourSquare recommendations in 2004. The venture-backed startup claims that prior authorization still reduces friction while chemotherapy is delayed. The health system is launching an innovation center equipped with reclaimed wood conference tables and an espresso bar, and a GoFundMe campaign helps patients afford deductibles bigger than a used Volkswagen Scirocco.
Everyone within the medical community knows that these tensions exist. Few people say this clearly because too many livelihoods depend on pretending that the current system is sustainable.
Business incentives tell a clearer story than promotional campaigns.
UnitedHealthcare had sales of more than $400 billion last year. CVS Health has surpassed $350 billion. Cigna approaches the GDP of a midsize country.
Meanwhile, independent physician practices are collapsing, rural hospitals are disappearing, oncology practices are consolidating under private equity pressure, and patients are navigating reimbursement structures designed by people who seem to see Kafka’s novel as an operating blueprint.
The market consolidated precisely as incentives encouraged consolidation.
Insurance companies have discovered something the rest of the healthcare sector still finds difficult to acknowledge. Whoever controls repayment controls the system itself.
This means that all medical innovations eventually hit the same wall. Survival depends on your repayment policy.
Founders know it. Hospital executives know it. Perms know it. Investors certainly know.
You can build the greatest diagnostic AI platform in human history. If your insurance company denies coverage or buries your refund due to administrative complexities, congratulations on your beautiful science project.
You can build a special survival program. Even if insurance denies long-term rehabilitation, fertility preservation, cognitive support, nutritional counseling, or mental health services, patients still bear the brunt of the harm alone.
You could start a patient navigation company until every medical conference ballroom from San Diego to Orlando glows with backlit logos and optimism. If the underlying insurance architecture rewards denial, delay, and opacity, navigation becomes simply another coping mechanism layered on top of institutional dysfunction.
The healthcare industry is increasingly resembling city-built flood mitigation kiosks as it refuses to discuss hurricanes.
That hurricane has a giant insurance company logo on it.
The irony here is worth noting. American health care still openly centers on medicine. The system actually revolves around financial risk management.
Insurance companies do not fundamentally exist to maximize health outcomes. It exists to manage financial exposure. Sometimes these goals coincide. Sometimes they diverge violently.
Every doctor reading this knows exactly what I mean.
Every hospital CFO knows this.
Every founder who has quietly converted a startup because the refund code has changed knows it.
Every caregiver who’s exhausted from waiting 97 minutes while listening to a pan flute version of “Don’t Stop Believin'” knows it, too.
The healthcare industry often defends itself by pointing out its complexity. Healthcare involves regulations, compliance, clinical nuances, workforce shortages, fragmented infrastructure, an aging population, and a growing burden of chronic disease. It’s all true.
But complexity becomes profitable.
That difference changes everything.
Administrative complexity now serves as an operational reality and an economic moat. The entire sector benefits by helping employers, providers and patients navigate the complexity created by other sectors that benefit from that complexity. We have built a trillion-dollar ecosystem with a business model that relies on translation services between fragmented bureaucracies.
At some point it accidentally becomes invisible.
This does not mean that markets automatically fail or that private sector participation is inherently harmful. The opposing argument is also noteworthy. Properly aligned incentives can produce surprising results. Efficient reimbursement models, transparent pricing, aligned preventive care incentives, and reasonable risk pooling can dramatically improve patient protection while lowering long-term system costs.
But current incentives reward scale, opacity, influence, and administrative patience.
Patients experience these incentives as fatigue.
The healthcare industry still underestimates the political consequences of this fatigue.
For years, Americans have categorized medical suffering as a personal misfortune. Cancer happened to someone else. Bankruptcy happened elsewhere. The insurance denial belonged to a different family. The system then expanded its dysfunction to nearly every household in America.
Now everyone has a story.
- This is a delayed scan.
- Rejected medication.
- Impossible bill.
- Out-of-network anesthesiologist.
- The nightmare of pre-approval.
- “We regret to inform you” letter.
- The call was transferred 6 times in 3 hours and then disconnected.
- A family was forced into amateur actuarial science while their loved one sat in an intensive care unit bed.
- Healthcare didn’t feel like civic infrastructure. It’s starting to feel hostile.
This erosion of trust has devastating consequences for all institutions involved in health care. Pharma wonders why public trust has collapsed. Hospitals wonder why patient hostility has increased. Insurers wonder why public anger is growing. Policymakers wonder why health care is suddenly attracting populist volatility across the political spectrum.
People eventually realize when the system treats them like a revenue extraction unit wrapped in a diagnostic code.
The most dangerous mistake that medical insiders still make is assuming that patients lack systematic awareness. Patients understand incentives much better than the industry gives them credit for. They may not speak reimbursement terms or regulatory language, but they understand the consequences.
They understand that no one is accountable.
They understand that every institution shifts blame to another institution.
They understand that “coordination of care” means that the exhausted spouse now functions as an unpaid case manager, billing specialist, transportation coordinator, pharmacist, medical records clerk, and amateur lawyer.
That awareness creates political energy.
Health care leaders must pay close attention to what happens when millions of Americans across ideological lines begin to reach the same conclusions simultaneously. The insurance architecture that underpins modern American health care increasingly shapes labor markets, household economics, disability, entrepreneurship, timing of retirement, burden of care, and social trust itself.
It goes far beyond medicine.
The healthcare industry still acts as if patients are fragmented consumers navigating isolated problems. Reality has changed. Americans are increasingly aware of their shared structural exposure.
That realization explains why I wrote We the Patients.
I wanted to document the mechanisms behind the madness. I wanted readers to understand how incentives cause harm over time. I wanted health care officials to confront the gap between what they claim their systems provide and what regular people actually experience after an MRI, after a diagnosis, and after discharge papers are in their hands.
Most importantly, I wanted people to recognize that the source of their anger was rational.
Nothing will destabilize public trust more quickly than the fact that your survival depends less on medicine than on whether insurance companies decide that your care fits into their approved financial framework.
Once people see it clearly, they can’t see it.
This realization changes the way people vote, organize, spend, work, retire, build companies, evaluate institutions, and understand power itself.
And frankly, after 30 years of looking at this system from all angles, I think healthcare officials should spend a lot less time celebrating the theater of innovation and more time asking brutally simple questions.
Who actually controls reality when a patient hears the word ‘no’?
Matthew Zachary is a 30-year brain cancer survivor, co-founder of We The Patients, and author of We the Patients: Understanding, Navigating, and Surviving America’s Healthcare Nightmare (Wiley, May 2026).
