A manifesto on American healthcare Page 01 — The receipt

Wellness Facts

One healthy 28-year-old · San Francisco

Serving size 1 month

Amount per month You pay Insurance covers

Equinox all-access membership $300 $0

Barry's 8 classes $240 $0

Nutrition meal prep + clean groceries $250 $0

Supplements protein, creatine, vitamins $70 $0

Recovery massage, sauna, cold plunge $120 $0

Bloodwork annual panel, monthly share $40 $0

Wearable subscription $30 $0

Total wellness spend $1,050 $0

+ Pay your premium $120 —

Out of pocket $1,170 /mo

Per year $14,040

Rewards for being healthy $0

* Illustrative month. Equinox and Barry's at 2026 San Francisco list-price ranges; supplements near the U.S. survey average; meal prep, recovery, bloodwork and wearable are estimates. Premium is the average worker share of single employer coverage, $1,440 a year (KFF, 2025).

A manifesto on American healthcare Page 02 — The argument

The short version

You pay to stay healthy. The system gives you zero credit for it.

A healthy 26-year-old spends somewhere between $900 and $7,500 a year on staying that way. Depending on who they are, between 0% and 34% of it comes back. Here's why, in seven short pages.

Read it like a receipt.

01

To the IRS, your gym is a hobby.

Federal tax rules treat exercise, supplements and nutrition for general health as personal consumption, even when a doctor recommends them. Only things that look medical count.

Exhibit A — What your HSA or FSA will pay for

Counts as medical

Therapy
Lab tests
Body scans

Roughly 8–50% of a healthy person's wellness spend.

Doesn't count

Gym and classes
Supplements
Nutrition
Most wearables

The other 50–92%.

DENIED

…even if your doctor told you to.

02

Getting healthier can't lower your premium.

The ACA bans pricing on health status. That protects sick people, and it should. It also means nothing you do for your health shows up on your bill.

Exhibit B — Two 26-year-olds, one price

Trains 5x a week, sleeps 8 hours

Doesn't

Premium

Same.

By law.

03

There are four doors. None of them really open.

Four channels could, in theory, send wellness money back to you. Each is shut, disputed, out of reach, or taxed.

Exhibit C — The four doors

EXCLUDED

HSA / FSA

Tax-free, but gym, supplements and nutrition are off the list. Freelancers get no FSA at all.

DISPUTED

Doctor’s letter

Apps sell a letter of medical necessity off a quick survey. The IRS warned in 2024 that self-reported info doesn’t make it medical.

OUT OF REACH

Employer wellness program

The only legal way to reward health. Capped at 30% of coverage cost, and barely allowed outside employer plans.

TAXED

Lifestyle stipend

About 7–10% of employers offer one, typically $850–1,200 a year, taxed as wages.

04

Three people. Two get nothing back.

Real prices, assumed habits. Only the person with the richest employer benefits gets anything, about a third, and most of that is their plan paying for therapy.

Exhibit D — A year of wellness spend, and what came back

The freelancer San Francisco · aged off a parent plan

$5,425 spent · $0 back

100% unrewarded. No HSA, no FSA, no employer.

The Big Tech employee San Francisco · the best benefits money can buy

$7,516 spent · $2,567 back

66% unrewarded. The gym, the biggest line, still counts for nothing.

The minimizer Austin · Planet Fitness and a cheap watch

$862 spent · $0 back

100% unrewarded. Got an HSA in 2026. None of this qualifies.

Came back Spent, got no credit

05

The rule underneath all of it: get sick first.

Wellness only gets reimbursed once it's been medicalized — a diagnosis, a prescription or a clinician's letter. A healthy person, by definition, has none of those.

Exhibit E — Two paths to the same gym

You, healthy Join a gym $0 back

You, diagnosed Doctor prescribes exercise Join a gym Pre-tax dollars

The system rewards the patient, not the prevention.

06

2026 cracked the door. It didn't open it.

+ Every marketplace bronze and catastrophic plan is now HSA-eligible.

+ Direct primary care fees up to $150 a month can sit alongside an HSA.

× $500 a year of HSA money for the gym.

The gym provision passed the House and was dropped from the final law. More people got the account. The things they actually spend on still don't qualify.

So close.

07

What we're not saying.

Your gym isn't wasted money. You value it, and you'd buy it anyway. And the best trials we have, including an 18-month randomized study across 160 worksites, found that wellness programs didn't cut medical spending in the short run.

So this isn't a claim that insurers owe you a refund. It's simpler than that.

You invest in your own health every month. Nobody gives you credit for it. We think someone should.

Sweat Equity.

Get paid to be healthy.

A manifesto on American healthcare Page 03 — The state of affairs

The premium

The state of affairs, 2026

A healthy 26-year-old pays $3 to $5 of premium for every $1 of insurance benefit they can expect to get back.

01

You pay $6,800. Your coverage is worth about $1,900.

That $1,900 isn't a lowball. It prices catastrophe deliberately high — the cancer, the car crash, the ICU stay — and it still comes out at less than a third of the bill.

Exhibit A — Freelancer, 26, SF, cheapest unsubsidized silver plan

What you pay$6,827 / yr

What a fair price for your risk would be$1,871 / yr

$4,956 extra. Every year.

Fair price = the claims the plan can expect to pay for this person ($1,590) ÷ an 85% loss ratio.

02

Most years, you use almost none of it.

In a typical year you consume about $400 of care, and the plan pays around $250 of it: the free checkup. Under a $5,000 deductible, the plan pays nothing in three of these five kinds of year.

Exhibit B — 100 years of a healthy 26-year-old

Routine A sick visit or a generic prescription

60 in 100

$150

Minor Urgent care, labs, imaging

26 in 100

$1,000

Moderate ER with a CT, outpatient procedure

11 in 100

$5,000

Major Inpatient stay or surgery

2.5 in 100

$35,000

Catastrophic Cancer, major trauma, ICU

1 in 200

$150,000

The bottom two rows are what insurance is for. They're worth ~$1,340 a year.

03

Insurers can price four things. Your health isn't one of them.

Everything else that predicts cost gets pooled. A 26-year-old marathoner pays the same as a 26-year-old with Type 1 diabetes. And the age band caps a 64-year-old at 3x a 21-year-old, when their real cost runs closer to 5x.

Exhibit C — What your price is allowed to depend on

Allowed

Age (capped at 3:1)
Tobacco
Where you live
Family size

Pooled

Your health
Your habits
Your fitness
Your sex

Ages 21–29 get charged ~27% more than they cost.

04

Less than a third of your premium is for you.

The biggest leak isn't age. It's health-status pooling: you paying for everyone else's risk.

Exhibit D — Where each premium dollar goes

The freelancer Covered CA silver $6,827 premium

23%

18%

44%

15%

The Big Tech employee Employer PPO $10,735 premium

19%

69%

12%

The minimizer Cheapest bronze HMO $5,032 premium

31%

18%

36%

15%

Your own expected claims Subsidy to older members Subsidy to the rest of the pool Insurer admin, taxes, margin

Group plans don't age-rate each employee, so for the Big Tech employee age and health subsidies are one transfer to the rest of the workforce.

05

Over ten years, it's a down payment.

Same three people as page 02. The richer the plan looks, the bigger the gap — it's just hidden in your total comp.

Exhibit E — The overpayment, per person

The freelancer

26, SF, $140k 1099. Just aged off a parent’s plan.

Premium$6,827

Fair price$1,871

Paid per $1 of benefit$4.29

Overpaid, 10 years$77k

The Big Tech employee

26, SF, $185k W-2. Sees $1,503 on the paystub.

Premium$10,735

Fair price$2,332

Paid per $1 of benefit$5.23

Overpaid, 10 years$116k

The minimizer

28, Austin, $95k contractor. Cheapest bronze plan.

Premium$5,032

Fair price$1,853

Paid per $1 of benefit$3.19

Overpaid, 10 years$48k

Before investment return and before tax. Invested at 7%, the ten-year figures become $63k–$154k.

06

And 2026 made it worse.

Older and lower-income people are partly shielded by subsidies that rise with the premium. The healthy, single young adult absorbs the full sticker increase.

+26% Benchmark premiums in one year. Insurers filed a median ~15% more for 2027.

$62,600 The subsidy cliff is back. Earn a dollar more, single, and your help is $0.

$0 Subsidy for many young people even below the cliff: their plan is already cheaper than what they're expected to pay.

$10,600 Max out-of-pocket, up from $9,200. It's $12,000 in 2027.

07

So just don't buy it? You can't really.

The tail is real About 3 years in 100 carry a $35k+ event. Going bare trades a $5k overpayment for an uncapped bill.

Mandates California, Massachusetts, New Jersey, Rhode Island and DC fine you for going uninsured. California: at least $950.

Lock-in You can only buy in open enrollment. You can’t wait until you’re sick, so you buy before, at the pooled price.

Employer plans Decline coverage and your employer keeps its ~$9k contribution. It doesn’t come back as salary.

Cheap plans Bronze and catastrophic plans cost less because they pay less, not because they price your risk.

08

None of this is a bug.

Pooling is how sick and older people get coverage they can afford, and that matters. The system works because young, healthy people overpay. The problem is that they fund it in the dark.

The person paying for the system never gets to see the bill itemized. This is that bill.

A manifesto on American healthcare Page 04 — What people are saying

From Reddit

We asked the internet how they handle it.

Three threads, 130 comments, people who buy their own coverage. Here's what they actually do.

Exhibit A — The threads

r/selfemployed

“Self-employed and rarely see a doctor: how do you handle health coverage?”

21 comments · our post, Oct 2026

Self-buyers, mostly older or with families.

r/HealthInsurance

“Young people — has anyone added up what they paid vs. what their insurance paid out?”

48 comments · 5.6K views · our post, Oct 2026

Insurance-literate, moderators answering from the insurer’s side.

r/digitalnomad

“Health insurance for American nomads in America”

64 comments · 140 upvotes · 2021 thread

Closest to our person: a healthy 31-year-old who quit to start a company.

01

So people are building their own.

Nothing off the shelf fits, so people stack parts: something for the catastrophe, something cheap for everyday care, and a few tricks to time it all. This is the strongest signal in all three threads.

Exhibit B — The homemade stack

Layer 1 Catastrophe cover

A cheap exchange plan or catastrophic plan for the big one. Some go bare. Health shares are trusted by some and called useless by others.

Layer 2 Everyday care

A primary-care subscription around $120 a month, or cash prices, discount pharmacies and telehealth. One person puts real care spending under $3,600 a year.

Layer 3 Timing tricks

Quitting early in the year, shifting retirement contributions or living off savings to qualify for Medicaid or subsidies. Off-exchange plans through a broker.

One guy spent weeks on this — then asked someone to build a startup for it.

02

Figuring it out is half the cost.

A healthy 31-year-old who quit to start a company wrote up his setup as a guide. It got 140 upvotes. The second-most-upvoted reply, at 55, was simply that the American system is really complicated. A reader who had just quit said the guide changed their decision.

140 upvotes for one person's homemade guide

Weeks of research, and he still couldn't answer basic coverage questions

03

The one 28-year-old in the room.

Single, healthy, and flatly refusing to pay $300 a month.

The reply he got: one fall off a bike can mean a $100k bill. Both are right. That's the trap.

A manifesto on American healthcare Page 05 — Who's already trying

The solution map

Everyone sells a piece. Nobody sells the whole thing.

No one in the US sells a healthy 26-year-old catastrophe cover priced for their real risk, routine care without paying twice, and credit for the $1–3k a year they already spend on staying healthy. Every piece exists. The bundle doesn't.

01

First, count the hands in the pot.

Between your paycheck and your doctor sits a stack of middlemen. Each one is paid out of your premium. Above them, three rule-makers decide what any of them is allowed to do for you.

Exhibit A — Everyone between you and your care

The rule-makers

IRSDecides your gym isn't medical

CMS / ACA rulesBan pricing on your health

State regulatorsLicense carriers, police shares

YOU 26, healthy

Employer Picks your plan; premium comes out of your comp

Broker Paid a commission to sell you a plan

Marketplace HealthCare.gov or your state exchange

Reinsurer Insures the insurer

Insurer Can keep up to 20% of premium

Claims administrator Processes claims for self-funded plans

PBM Sets which drugs and what price

Network Decides which doctors count

Billing & clearinghouse Codes and routes every bill

Pharmacy Dispenses at the PBM’s price

Hospital system Sets its own list prices

Labs & imaging Billed separately, often surprising

YOUR
CARE the doctor, finally

New hands, 2025–26

HSA custodiansHold the tax break

Checkout railsTruemed, Sika, Flex: a fee on the tax break

ICHRA platformsThatch and co. route employer dollars

Health sharesA pool with no guarantee to pay

A dozen hands. Not one pays you for staying healthy.

02

Six kinds of fix are already out there.

Each one works for a piece of the problem. None of them works for all of it.

Exhibit B — The map

A NO GUARANTEE

Health shares and crowd-pay

CrowdHealth, Knew Health, Zion, Medi-Share and others · ~1.5M members

Real demand at $150–200 a month. But no guarantee to pay, and states are closing in.

B WORKS

Primary care by subscription

3,600+ practices, growing 19% a year · 85% stay a year

It works, at $50–85 a month. VC clinic chains (Forward, Carbon Health) didn’t.

C GRAVEYARD

Bundles for individuals

Decent, Sidecar, Taro/Mending, Mishe

Every one died, pivoted or retreated to employers.

D GROUP ONLY

Paying people to be healthy

Vitality (54M members worldwide), Curative (165k, profitable), step apps

Works inside employer and group plans. Consumer-funded rewards pay pennies and fade.

E PROVEN SPEND

Prevention people already buy

Function (100k+ at $365/yr), Hims (2.9M subscribers), Whoop, Oura

People pay for it, happily. Checkout rails make it pre-tax: one tax break, five vendors.

F THE CHANNEL

Employer dollars, individual plans

ICHRA: 500k+ people, 56% under 45 · Thatch, Remodel, Take Command

The one channel that reaches young, healthy buyers with a budget attached.

03

Everyone who tried to bundle it died the same way.

Two causes, every time. They became a small insurance company carrying individual-market risk. And they paid too much to find each customer one at a time. The survivors all fled to selling through employers.

Exhibit C — The graveyard

R.I.P. Decent 2019–2023 Primary care + catastrophic plan in Texas. 94% laid off.

R.I.P. Sidecar individual plans, –2024 Cash-price plans. Now employer-only.

R.I.P. Taro / Mending –2027 Its own ACA carrier. Under state supervision at ~1,100 members.

R.I.P. Mishe consumer, –pivot Cash-pay for consumers. Now sells to payers.

04

Insurers couldn't reward you even if they wanted to.

This is the most important thing on the map. Four rules wall it off for any licensed carrier selling to individuals.

Exhibit D — The wall

Can’t price on behavior Community rating bans charging healthy habits less.

Can’t keep the upside Risk adjustment moves money away from any plan with healthy members.

Can’t pay back the healthy Required rebates go to every member equally.

Can’t offer wellness discounts Premium-linked rewards are legal in group plans only.

So the reward can't come from your premium.

05

It has to come from somewhere else.

There are three places the money can legally come from.

1 The tax break Since January 2026, every bronze and catastrophic plan is HSA-eligible, and a primary-care subscription up to $150 a month can sit beside it.

2 The vendor margin Buy the gym, the labs and the recovery people already pay for at a better rate, and pass the difference back.

3 The employer chassis Inside employer plans and ICHRA, health-based rewards are legal. ICHRA already covers 500k+ people, 56% of them under 45.

06

Five problems. One has no answer at all.

Exhibit E — What a healthy 26-year-old can buy today

The problemBest answer todayThe gap

Catastrophe cover costs too much for my riskHealth shares (no guarantee) or bronze from $346/moCheap and guaranteed doesn’t exist

I pay twice: premium, then deductibleCurative’s $0 out-of-pocket planEmployers only

Routine care is a hasslePrimary-care subscriptions, One MedicalWorks, but hard to find and stack

Going bare locks me outKeep a real planNo way around it

No credit for what I spend staying healthyNothing for individuals in the USNobody. This is the open slot.

That last row is the open slot.