Matt dives into a specific healthcare topic to help those in the industry, and those outside of it, better understand the market drivers causing today’s healthcare challenges.

UnitedHealth runs more than 2,600 companies, and you have heard of maybe a dozen. The outfit that denies your claim may also own your clinic, your pharmacy, and the data broker that scored your risk before you ever filled out a form. We did not build a healthcare market. We built a machine that pays itself and files the patient under expenses.

I have watched this industry reorganize itself more times than I can count, and the pattern never changes. Every reshuffle promises efficiency. Every reshuffle ends with fewer independent voices in the room and one more layer between the patient and the person who decides their care. The Sunlight Report on UnitedHealth Group, published this year by the Center for Health & Democracy, finally put a number on the machine. The number should stop you cold.

Researchers built the Sunlight Report by drilling through Schedule Y filings, the disclosures insurers must send to state regulators listing every subsidiary they control. By the third quarter of 2024, those filings showed UnitedHealth Group operating 2,694 subsidiaries and affiliates. In 2010 the company controlled 149. That is nearly a twentyfold jump in thirteen years, and analysts who track the filings believe the count now pushes past 3,000, after roughly 250 new entities appeared in a single year.

Here is the part that tells you what the structure exists to do. In 2024, UnitedHealthcare collected 298.4 billion dollars and Optum collected 253 billion, which adds to 551.4 billion. The parent reported consolidated revenue of 400.3 billion. The 150.9 billion dollar gap between those figures carries a bland accounting name: intercompany eliminations. Translated, it means money the company paid itself and then erased from the total. That internal river has swollen from 18.3 billion in 2010, when it made up 16.2 percent of revenue, to more than 150 billion in 2024, or 27.2 percent. More than a quarter of the enterprise now runs on payments it routes to itself.

Follow the profit and the design gets clearer. Optum earned lower revenue than the insurance arm, yet it generated 16.7 billion of the parent's 32.3 billion in profit, which is 52 percent. The care-delivery side pays the freight. The patient sitting across from a UnitedHealth-owned doctor, filling a script at a UnitedHealth-owned pharmacy, appeals a denial to the same enterprise that just billed itself for the visit. You show up as a line item in a ledger that already knows how the story ends.

Think about what that does to a sick person trying to get care. A patient with a chronic condition now negotiates with an enterprise that sits on every side of the table at once. The insurer decides coverage. The insurer's clinic delivers the treatment. The insurer's pharmacy benefit manager sets the formulary. The insurer's data operation scores the risk. Nobody in that loop answers to the patient, because the loop closes before the patient ever gets a vote. When one company holds every seat, the person the system claims to serve becomes the only party without leverage.

People assume the Affordable Care Act put a leash on insurer profit. It tried. The medical loss ratio rule forces insurers to spend 80 to 85 cents of every premium dollar on actual care, and to rebate the difference when they fall short. On paper, that caps how much an insurer keeps.

Read where the rule stops. It governs the insurance company. It says nothing about the doctors, clinics, pharmacies, and data brokers that same company owns. So the play writes itself. Buy the provider. Route the spend into the entity you control. Call it medical spending on one side of the house and profit on the other. When the insurer owns the doctor, the 80 to 85 rule stops protecting anyone, because the money never has to leave the family.

UnitedHealth built its empire on exactly that logic. Nearly 80 percent of its acquisitions bought care providers, not hospitals with their thin margins, but the profitable links in the chain. The company now employs close to one in ten physicians in the country, moves roughly 20 percent of the prescription drug market through Optum Rx, and controls about 30 percent of Medicare Advantage. The advocates who live inside this system saw it long before the headlines. One patient advocate in HIV care put it plainly in our ELAVAY research: payers have gamed the system through mid-year formulary changes and self-dealing via vertical integration, carving out high-cost care under a banner of delay and deny until patients give up. That advocate named the machine two years before the Sunlight Report counted its parts.

They built this on purpose. The structure performs precisely as designed, and it will keep performing until someone with standing forces a different design.

Watch the regional systems copy the playbook. This July, Intermountain Health and AdventHealth announced plans to form a joint venture combining their Denver-area operations. Two large systems, one combined footprint, fewer separate decision-makers across a metro region. Each deal like it arrives wrapped in the language of coordination and better care. Each deal also removes a chair from the table where patients and their advocates try to sit. Meanwhile the payment system keeps rewarding size. For 2026, CMS finalized a 2.6 percent raise for hospital outpatient departments and pressed forward on site-neutral policies that decide how much a service costs based on who owns the building where it happens. Every fight over site-of-service is really a fight over ownership, and ownership keeps concentrating. The bigger the enterprise, the harder it leans on the rules.

Consolidation does something quieter than raise prices. It shrinks the number of independent voices left to challenge a decision. And when a merged system tightens its spreadsheet, the advocacy function goes first. Our ELAVAY data shows the pattern in the industry's own words. Advocates describe watching companies centralize their efforts until a dedicated advocacy role becomes a downgraded slice of somebody else's job. Merck, a top-three performer with advocacy leaders in 2024 at a 5.14 rating, slid to 4.73 the following year as its engagement lost momentum. The chair does not disappear in a press release. It disappears in a reorg, one budget line at a time, and patients feel the absence long before anyone announces it.

Count what the patient loses each time a chair goes empty. Fewer advocates means fewer people who can spot a harmful formulary change before it hits a pharmacy counter. It means fewer coalitions with the standing to challenge a prior-authorization wall. It means fewer plain-language explainers that help a newly diagnosed family understand their options while they still have options. Consolidation sells itself as tidier care, yet every merger that trims the advocacy line trades the patient's last independent ally for a rounding error on a balance sheet. Advocates rarely get to argue that trade in the room where someone makes it. Data lets them argue it before the room ever convenes.

The companies that hold patient trust do the opposite of hide. They fund an advocacy function with real authority. They measure how the advocacy community actually sees them instead of guessing from a conference booth. Then they act on what they hear.

The ELAVAY top tier shares one trait. They treat advocacy organizations as a negotiating party, not a courtesy invite. Johnson & Johnson held the number one position on the strength of a maintained advocacy force, keeping dedicated people in the field while competitors pulled back. AbbVie climbed into the top ten after years outside the top fifteen by becoming genuinely more responsive to advocacy needs. Advocates can tell the difference in a handshake. As one industry relations leader told us, the transformational partners are the individuals truly dedicated to the work, the ones out in the field whose goal is helping physicians and patients rather than selling. You can feel it in the room. You know when someone sits across from you to move a problem and when they sit across from you to close a quarter.

That difference reaches the patient directly. When a company funds advocacy with authority, patients get plain-language education about their disease, real help navigating a denial, and an organization with the standing to push back on a mid-year formulary switch before it lands. When a company guts advocacy to trim a budget, patients get a call-center script and a longer wait. The advocacy function is the last independent voice standing between a consolidated system and a patient it has already priced. Fund it, and you protect that voice. Starve it, and you hand the patient to the machine.

You ghost your own socials by Wednesday. SureThing learns your voice and ships native posts to LinkedIn, X, Instagram, and TikTok, without you writing a thing.

Post in Your Voice

So here is where I land it, for the two audiences reading this.

The 2026 ELAVAY report shows exactly where companies stand with the advocacy community, which leaders the field trusts, and where the gaps sit before they become someone's excuse to consolidate. It turns a soft relationship into a hard number, and a hard number survives a budget review in a way a good intention never will. If you want to see the findings or talk through where your organization lands, reach me directly at [email protected].

The machine already knows what it wants to do with the patient. The only real question is whether anyone with standing still owns the fight on the patient's side. Advocacy answers that question, and data gives advocacy the standing to make the answer stick. That is the job. I intend to keep doing it.

Source article: https://open.substack.com/pub/healthcareuncovered/p/the-sunlight-report-on-unitedhealth