By Dutch Rojas
In every empire, there is a hidden court. A ruling elite whose power is felt but rarely seen.
In American healthcare, that court is not found in hospital boardrooms or surgical theaters. It resides in the offices of five corporate behemoths:
UnitedHealth. CVS. Elevance. Cigna. Centene.
Together, they now control 46% of the U.S. insurance market. But “insurance” is too narrow a term. They don’t merely process claims. They orchestrate the system.
This vertical integration resembles nothing so much as the great zaibatsu of pre-war Japan—corporate conglomerates that owned everything from raw materials to retail outlets.
Except healthcare’s Five Families have achieved something even Mitsubishi never managed: control of a sector comprising one-fifth of the world’s largest economy.
They own the physician networks.
They own the pharmacies.
They own the PBMs.
They even own the algorithms that decide whether you’re approved or denied.
Consider UnitedHealth Group:
$395 billion in annual revenue, 400,000 physicians in its networks, and Optum’s data analytics that process 14.7 trillion healthcare transactions annually.
This is not innovation. It is quiet domination.
The consolidation was swift and strategic. Between 2006 and 2016 alone, these insurers executed 400+ acquisitions, primarily in data, pharmacy, and physician practices.
Unlike European systems with countervailing regulatory powers or Japan’s post-war reforms that dismantled similar concentrations, America’s healthcare oligopoly faces remarkably little resistance.
Worse, they lobby against the very reforms that would bring balance.
Site-neutral payments, a modest correction that would stop hospitals from charging 600% of Medicare for the same treatment a physician delivers at 80%, is sabotaged at every turn.
Price transparency? Obstructed.
Preauthorization reform? Delayed.
PBM rebates and backdoor kickbacks?
Defended with $71 million in annual lobbying.
These firms do not deliver care.
They do not heal the sick.
But they profit from every transaction that does.
In the final accounting, this isn’t a broken system. It’s a rigged one, with the Five Families at the top.
And like all empires built on extractive institutions rather than productive innovation, it cannot sustain itself indefinitely.
