Pearl is a clinical professor of plastic surgery at the Stanford University School of Medicine and is on the faculty of the Stanford Graduate School of Business. He is a former CEO of The Permanente Medical Group.
In healthcare, as in life, people devote a lot of time and attention to the way things should be. They’d be better off focusing on what actually could be.
As an example, 57% to 70% of American voters believe our nation “should” adopt a single-payer healthcare system like Medicare For All. Likewise, public health advocates insist that more of the nation’s $4 trillion healthcare budget “should” be spent on combating the social determinants of health: things like housing insecurity, low-wage jobs and other socioeconomic stresses. Neither of these ideas will happen, nor will dozens of positive healthcare solutions that “should” happen.
When the things that should happen don’t, there’s always a reason. In healthcare, the biggest roadblock to change is what I call the conglomerate of monopolies, which includes hospitals, drug companies, private-equity-staked physicians and commercial health insurers. These powerful entities exert monopolistic control over the delivery and financing of the country’s medical care. And they remain fiercely opposed to any change in healthcare that would limit their influence or income.
This article concludes my five-part series on medical monopolies with an explanation of why (a) “should” won’t happen in healthcare but (b) industrywide disruption will.
Why government won’t lead the way
With the U.S. Senate split 51-49 and with virtually no chance of either party securing the 60 votes needed to avoid a filibuster, Congress will, at most, tinker with the medical system. That means no Medicare For All and no radical redistribution of healthcare funds.
Even if elected officials started down the path of major reform, healthcare’s incumbents would lobby, threaten to withhold campaign contributions (which have exceeded $700 million annually for the past three years) and swat down any legislative effort that might harm their interests.
In American politics, money talks. That won’t change soon, even if voters believe it should.
American employers won’t lead, either.
Private payers wield significant power and influence of their own. In fact, the Fortune 500 represents two-thirds of the U.S. GDP, generating more than $16 trillion in revenue. And they provide health insurance to more than half the American population.
With all that clout, you’d think business executives would demand more from healthcare’s conglomerate of monopolies. You might assume they’d want to push back against the prevailing “fee for service” payment model, replacing it with a form of reimbursement that rewards doctors and hospitals for the quality (not quantity) of care they provide. You’d think they would insist that employees get their care through technologically advanced, multispecialty medical groups, which deliver superior outcomes when compared to solo physician practices.
Instead, companies take a more passive position. In fact, employers are willing to shoulder 5% to 6% increases in insurance premiums annually (double their average rate of revenue growth) without putting up much or any resistance.
One reason they tolerate hefty rate hikes—rather than battling insurers, hospitals, and doctors relates to a surprising truth about insurance premiums. Business leaders have figured out how to transfer much of their added premium costs to employees in the form of high-deductible health plans. A high deductible plan forces the beneficiary to pay “first dollar” for their medical care, which significantly reduces the premium cost paid by the employer.
Businesses also realize that high deductibles will only financially burden employees who experience an unexpected, catastrophic illness or accident. Meaning, most workers won’t feel the sting in a typical year.
Leading the healthcare transformation
If there were a job opening for “Leader of the American Healthcare Revolution,” the applicant pool would be shallow.
Elected officials would shy away, fearing the loss of campaign contributions. Businesses and top executives would pass on the opportunity, preferring to shift insurance costs to employees and the government, or simply because the time and effort would distract their focus on what they do best: run a business. Patients would feel overwhelmed by the task and the power of the incumbents. Doctors, nurses and hospitals—despite their frustrations with the current system—prefer to take small steps, fearful of the conglomerate of monopolies and the risks of disruptive change.
To revolutionize American medicine, a leader must possess three characteristics:
1. Sufficient size and financial reserves to disrupt the entire industry (not just a small piece of it).
2.Presence across the country to leverage economies of scale.
3.Willingness to accept the risks of radical change in exchange for the potential to generate massive profits.
Whoever leads the way won’t make these investments because it “should happen.” They will take the chance because the upside is dramatically better than sitting on the sidelines.
The likely winner: American retailers
Amazon, CVS, Walmart and other retail giants are the only entities that fit the revolutionary criteria above. In healthcare’s game of monopoly, they’re the ones willing to take the high-stakes risks needed to disrupt the industry given the enormous profit that success would generate.
The process of moving forward has already started. For years, these retailers have been acquiring the necessary game pieces (including pharmacy services, health-insurance capabilities, and innovative care-delivery organizations) to someday take over American healthcare.
CVS Health owns health insurer Aetna. It bought value-based care company Signify Health for $8 billion, along with national primary care provider OakStreet Health for $10.6 billion. Walmart recently entered into a 10-year partnership with the nation’s largest insurance company, UnitedHealth, gaining access to its 60,000 employed physicians. Walmart then acquired LHC, a massive home-health provider. Finally, Amazon recently purchased primary-care provider One Medical for $3.9 billion and maintains close ties with nearly all of the country’s self-funded businesses.
Harvard business professor Clay Christensen noted that disruptive change almost always comes from outsiders. That’s because incumbents cling to overly expensive and inefficient systems. The same holds true in American healthcare.
The retail giants can see that healthcare is exorbitantly priced, uncoordinated, inconvenient and technologically devoid. And they recognize the hundreds of billions of dollars of revenue and they could earn by offering a consumer-focused, highly efficient alternative.
How will the transformation happen?
Initially, I believe the retail giants will take a two-pronged approach. They’ll (a) continue to promote fee-for-service medical services through their pharmacies and retail clinics (in-store and virtual) while (b) embracing every opportunity to grow their market share in Medicare Advantage, the capitated option for people over age 65.
And within Medicare Advantage, they’ll look for ways to leverage sophisticated IT systems and economies of scale, thus providing care that is better coordinated, technologically supported and lower cost than what’s available now.
Rather than including all community doctors in their network, they’ll rely on their own clinicians, augmented by a limited cohort of the highest-performing medical groups in the area. And rather than including every hospital as an inpatient option, they’ll contract with highly respected centers of excellence for procedures like heart surgery, neurosurgery, total-joint replacement and transplants, trading high volume for low prices.
Over time, they’ll reach out to self-funded businesses to offer proven, superior clinical outcomes, plus guaranteed, lower total costs. Then they’ll make a capitated model of their preferred insurance plan for all companies and individuals. Along the way, they’ll apply consumer-driven medical technologies, including next generations of ChatGPT, to empower patients, provide continuous care for people with chronic diseases and ensure the medical care provided is safe and most efficacious.
While the potential benefits of a customer-focused company leading the transformation of medical care in the United States are great, the risks and the uncertainties are many. Ultimately these are for-profit companies whose first priority is their shareholders and all have been criticized for how they treat their employees.
Tommy Lasorda, the long-time manager of the Los Angeles Dodgers, once remarked, “There are three types of people. Those who watch what happens, those that make it happen and those who wonder what just happened.”
Lasorda’s quip describes healthcare today. The incumbents are watching closely but failing to see the big picture as retailers acquire medical groups and home health capabilities. The retail giants are making big moves, assembling the pieces needed to completely transform American medicine as we think of it today. Finally, tens of thousands of clinicians and thousands of hospital administrators are either ignoring or underestimating the retail giants. And, when they get left behind, they’ll wonder: What just happened?
The conglomerate of monopolies rule medicine today. Amazon, CVS and Walmart believe they should rule. And if I had to bet on who will win, I’d put my money on the retail giants.
A golden tray sits on the Resolute Desk as President Donald Trump speaks during an announcement on American nuclear innovation in the Oval Office at the White House on July 24, 2026, in Washington, D.C. Trump is signing multiple executive orders targeting the nuclear energy sector and easing rules for new reactors and nuclear fuel supply chains.
Trump’s hubris rivals the fallen heroes of ancient Greek mythology
In January, the New York Times asked President Donald Trump if there were any limits on his global powers.
“Yeah,” the president responded, “there is one thing. My own morality. My own mind. It’s the only thing that can stop me.”
That was eight months ago, but fortunately Christopher Nolan’s blockbuster adaptation of “The Odyssey” has made ancient Greek literature newly relevant. Before that window closes, I’d like to talk about hubris.
Today, the term mostly means excessive pride or arrogance. That’s part of what the Greeks meant by it too, but the meaning was a bit richer and more specific. Hubris was an insolent or outrageous act that offended the gods, often because the transgressor was claiming abilities or authorities that solely belonged to supreme beings.
Nolan renamed and slightly modified the concept of xenia for the film, calling it “Zeus’ law.” In the director’s telling, mortals should follow the rules laid out by the gods, specifically the requirement to treat strangers with respect lest they be gods in disguise.
In a sense, hubris is the opposite, or at least the rejection, of xenia. The hubris of the suitors, and at times Odysseus himself, invites punishment by the gods and their mortal instruments.
Which brings me back to Donald Trump. His claim that there are no constraints on his personal power to dictate events on the global stage was one of the greatest expressions of hubris ever uttered by a political leader.
Trump’s claim was obviously false when he made it.
He vowed that he could end the Russia-Ukraine war in 24 hours. He’s proved powerless to make that happen. If he had divine powers to work his will, why would he have balked at implementing his tariffs so often that Wall Street adopted the “TACO trade” term for his deals? “TACO” stands for “Trump always chickens out.”
And why would Trump have made so many embarrassing concessions to China — from rescinding tariffs on Chinese goods to allowing them to buy crucial and incredibly valuable computer chips?
But Trump saw his success at capturing Venezuelan strongman Nicolas Maduro as proof of his ability to launch missiles to the same effect as Zeus’ lightning bolts. Trump believed he was the most powerful man who ever lived.
This is no exaggeration. In March, when the Iran invasion seemed successful, Trump gave a document penned by“Presidential Historian David King” to New York Times reporters Maggie Haberman and Jonathan Swan purporting to prove that Trump was “the most powerful person to have EVER walked this planet.” King was, in fact, a businessman and occasional caddy for legendary golfer Gary Player.
King compared Trump favorably to many of history’s most powerful, and often heinous, figures: Alexander the Great, Attila the Hun, William the Conqueror, Napoleon Bonaparte, Joseph Stalin, Genghis Khan, Mao Tse Tung, Adolf Hitler and Vladimir Lenin. Many of these men thought they were the most powerful person in the world, too. And many were defeated precisely because they believed it.
At least Napoleon and Hitler had a string of truly impressive victories before they learned the folly of hubris. The limits on Trump’s power have been exposed by far less august forces than the combined might of the allies in World War II or the fearsome Russian winter.
Iran is a comparatively middling power. But the regime’s ability to absorb punishment while imposing its will on the Strait of Hormuz has proved to be a greater constraint on Trump’s power than his morality or mind. We should note that, at least rhetorically, his morality has not proved much of a constraint. He has repeatedly promised to destroy Iranian “civilization” if the regime refuses to capitulate.
But they haven’t — and won’t anytime soon — because the regime’s tolerance for pain far outstrips Trump’s. The combined fear of skyrocketing oil prices, outrage of Gulf state potentates, diminishing weapon supplies and domestic unpopularity is doing the work that international law, congressional oversight and the collective opinion of foreign policy experts can’t or won’t do.
If I considered Trump more heroic than reason and facts could allow, I would say his Sisyphean predicament has the whiff of Greek tragedy to it. Trump is vexed by the fact that the Iranians won’t honor deals or ratify his countless premature claims of victory — giving new meaning to his vow that his presidency would make people tired of winning. It’s almost like they’re out-Trumping Trump.
Things might have gone better if he’d heeded that great Greek tragedian Sophocles: “For Zeus utterly abhors the boasts of a proud tongue.”
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Jonah Goldberg is editor-in-chief of The Dispatch and the host of The Remnant podcast. His Twitter handle is @JonahDispatch.