The Co-Pay: How They Charge You
The Pentagram — Part 3: Health Care
Health Care is the only industry in the pentagram where your ideal outcome is their worst outcome.
Think about that. With Energy, the utility wants you to consume — the more you use, the more they bill. With Transportation, the auto industry wants you to drive — the more miles, the more gas, the more wear, the more replacement. With Housing, the mortgage lender wants you to borrow — the bigger the house, the bigger the loan, the more interest. With Food, the supermarket wants you to buy — the more you eat, the more they sell.
Health Care is different. Your ideal outcome — perfect health, a strong body, a clear mind, never needing to walk through their doors — generates zero revenue. A healthy person is a non-customer. A well person is a financial non-event. The system does not get paid when you are well. The system gets paid when you are sick. And the sicker you are, and the longer you stay sick, and the more complex your sickness becomes, the more the system collects.
This is not a conspiracy claim. I keep saying that, and I'll keep saying it until it sticks, because the word "conspiracy" is the reflexive screen that allows people to dismiss structural criticism without engaging it. This is an incentive-structure observation. Fee-for-service medicine — the dominant payment model in the United States — pays doctors per procedure, per visit, per prescription. Every scan, every blood draw, every specialist referral, every follow-up appointment is a billable event. The financial incentive of the entire apparatus points in one direction: toward chronic illness management. Not toward cure. Not toward prevention. Toward management — the indefinite, recurring, billable maintenance of conditions that never quite resolve.
Prevention is revenue destruction. A patient who never gets sick is a patient who never pays. And a system built on payment-per-sickness has no structural incentive to keep you from getting sick in the first place.
The Subterfuge Principle, as always: the industry calls itself "Health Care." It is not Health Care. It is Sick Care. Health care would be teaching you to grow beets and ginger and get your heart rate over 122 for 22 minutes a day. Health care would be showing you how to read your own bloodwork, understand your own inflammation markers, and recognize the early signals your body sends before things go wrong. What this industry provides is intervention after the damage is done — at maximum billable cost, through a pricing system so opaque that you cannot determine what anything will cost until the bill arrives weeks later.
That's not care. That's collection.
Health insurance is not insurance.
Insurance, in any actuarial sense, is a product that protects against unlikely, catastrophic events. House fires. Car accidents. Natural disasters. You don't use your homeowner's insurance to pay for lightbulbs. You don't file an auto insurance claim for an oil change. Insurance exists for the low-probability, high-cost events that would bankrupt you if you had to cover them alone.
Health "insurance" is expected to cover routine maintenance. Checkups. Prescriptions. Blood tests. Minor illness. The annual physical. The thing your kid caught at school. You're expected to run this through insurance because the out-of-pocket cost of even basic care has been inflated so far beyond reason that most people cannot afford to pay directly. A fifteen-minute doctor's visit that costs $35 in Mexico or $60 in Portugal costs $250 to $400 in the United States — before labs, before imaging, before the prescription that follows.
The insurance became necessary because the underlying costs were made insane. And who made them insane? The insurance companies, through a mechanism called the chargemaster — and I need you to understand this mechanism because it is the engine of the entire extraction.
Every hospital maintains a chargemaster — a list of prices for every service, every supply, every procedure. And the prices on that list are absurd by design. $50 for a single aspirin tablet. $300 for a saline bag that costs $0.86 to manufacture. $15 for a single-use surgical glove. $500 for a "room use fee" assessed for sitting in a curtained-off section of the emergency department. These prices were never meant to be paid. They exist as the starting point for negotiation with insurance companies. The insurance company "negotiates" the $50 aspirin down to $8, and then presents that $8 as evidence that it saved you $42. The insurance company is the hero. The hospital is the reasonable partner. And the patient pays the copay and never sees the math.
But the patient without insurance gets the chargemaster price. The full $50 aspirin. The full $300 saline bag. The system doesn't just fail the uninsured — it punishes them. For being uninsured. For failing to participate in the extraction loop. The person who can least afford the inflated price pays the most inflated price. By design.
And then there's the labyrinth. Premium. Deductible. Copay. Coinsurance. Out-of-pocket maximum. In-network. Out-of-network. Prior authorization. Surprise billing. The terminology alone requires a graduate degree to navigate, and the complexity is not a failure of the system. The complexity is the system. It is deliberately constructed so that you cannot calculate your actual cost before you receive a service. You cannot price-shop. You cannot compare. You are making a purchasing decision blind, under duress — because you are sick, or your child is sick, or something hurts and you're afraid — with no time to research, no leverage to negotiate, and in many regions, no alternative provider.
This is not a market. This is a hostage situation with a payment plan.
And the deepest hook of all: health insurance is tied to employment. Lose the job, lose the insurance. This coupling is not accidental. It is the single most effective labor-compliance mechanism in the American economy. People stay in jobs they hate — jobs that damage them, jobs that bore them hollow, jobs that waste their Trident — because the alternative is uninsured access to a system that charges $50 for aspirin. The pentagram, tightening: Housing requires a job (mortgage). The job provides insurance (Health Care). The insurance enables you to maintain the body (Health Care) that gets transported (Transportation) to the job that pays for the house. Cut any wire and the whole circuit fails. The institution knows this. The institution depends on this. Your fear of losing insurance is their most reliable guarantee that you will show up on Monday.
Nested inside the Health Care pillar, like a parasite inside a host, is the pharmaceutical industry. It deserves its own treatment, and it's going to get it, because the extraction is layered in ways that make the chargemaster look straightforward.
Patent manipulation. The industry calls it "evergreening" — making minor modifications to an existing drug to extend the patent and prevent generic competition. Change the coating. Adjust the delivery mechanism. Combine it with another drug that was already available separately. The modification doesn't improve the medication in any clinically meaningful way. But it resets the patent clock, and as long as the patent holds, no generic competitor can enter the market, and the price stays whatever the manufacturer says it stays. The institution does not innovate to help you. It innovates to maintain its monopoly. The Subterfuge Principle: if the motive were therapeutic, the patent would expire and the generic would flow. The motive is revenue, and the patent is the dam.
Direct-to-consumer advertising. The United States and New Zealand are the only two countries on earth that allow pharmaceutical companies to advertise prescription drugs directly to patients. Two countries out of nearly two hundred. "Ask your doctor about [brand name]." Think about that sentence. You are being marketed to — on television, on your phone, in magazines, on billboards — so that you will walk into a physician's office and request a specific, expensive, branded product that the physician might not have otherwise prescribed. You are the sales force for your own extraction. The pharmaceutical company doesn't need a sales rep in the exam room. They have you. And you'll even make the pitch sincerely, because you saw the commercial and the people in the commercial were smiling and walking on beaches and the side effects were listed so quickly that your brain didn't register them.
Pharmacy Benefit Managers — PBMs — are the middlemen's middlemen. They sit between the drug manufacturer, the insurer, and the pharmacy, negotiating prices that none of the other parties can see. They collect rebates from manufacturers — essentially kickbacks for steering prescriptions toward preferred drugs — and those rebates are not passed through to patients. They direct prescriptions to preferred pharmacies, which they often own. The entire operation is opaque by design, because if you could see the math — if you could trace a single pill from the factory to the pharmacy shelf and add up every hand that touched it and every cut that was taken — you would see theft. Not the crude kind, with a mask and a gun. The elegant kind, with contracts and confidentiality clauses and a pricing structure so deliberately complex that no patient, no doctor, and no pharmacist can reconstruct the real cost of the thing in the bottle.
And then there's the opioid case study, which I include not because it's unique but because it's the clearest demonstration of the system working as designed. The pharmaceutical industry manufactured an addiction epidemic. It marketed OxyContin as non-addictive. It funded studies that minimized the risk. It pressured doctors to prescribe. It flooded communities with pills — enough pills, in some counties, for every man, woman, and child to have a daily dose for years. Hundreds of thousands of people died. And then the same industry pivoted to selling the treatment for the addiction it created. Suboxone. Naloxone. Vivitrol. New revenue streams, derived from the wreckage of the old revenue stream.
This is not an aberration. This is not a rogue actor exploiting a fundamentally sound system. This is the system working exactly as its incentives demand: create the illness, sell the cure, manage the chronic condition, bill perpetually. The opioid crisis didn't break the Health Care pillar. It demonstrated the Health Care pillar. And if that doesn't activate the Subterfuge Principle in your mind, nothing will.
In the last two decades, independent hospitals and physician practices across the country have been systematically acquired by large health systems. Consolidated. Absorbed. The independent doctor with a private practice — the one who knew your name, set her own prices, and didn't answer to a corporate board — has been replaced by a physician employed by a regional health system that controls every hospital, most specialist practices, and the urgent care clinics in a fifty-mile radius.
The result is documented across multiple studies: prices increase 20 to 40% after acquisition. The same doctor. The same procedure. The same building. But now there's a "facility fee" attached to every visit — a charge for the privilege of being seen in a building that the health system owns, which is a charge that didn't exist when the building was a private practice. You are paying more for the same thing. The difference goes to the system.
Choice disappears. In many regions, one health system controls the market. You "choose" a provider the way you "choose" an electricity provider — from a list of one. The monopoly structure of Energy, replicated in Health Care. The pentagram rhymes with itself.
And here's the subterfuge that should make you furious: most large health systems are classified as nonprofits. Tax-exempt. No property tax. No income tax. They use this tax advantage — this designation that was designed to protect charitable organizations — to acquire more practices, build more facilities, expand their monopoly, and pay their executives $5 to $15 million per year. The nonprofit designation is the costume. The Subterfuge Principle: if the motive were charitable, the executive compensation would not be indistinguishable from a Fortune 500 CEO.
Here's where we come back to Can You Take Shit?, because the exits from this pillar are not hypothetical. They are the things I've already told you to do.
The cold-pressed juice. The 122 beats per minute for 22 minutes. The growing of your own food. The martial arts training that gives you the humble confidence that changes your gait. These are not lifestyle preferences. They are not wellness influencer content. They are partial exits from the Health Care pillar.
Nutrition as medicine. The Food pillar — we'll get to it in Part 5 — feeds you pathogenic inputs. Pesticides, preservatives, additives engineered to a bliss point that triggers dopamine. The Health Care pillar bills you for the consequences. These two pillars are business partners, whether they know it or not. Growing your own food — even one tomato plant in a five-gallon bucket on a balcony in a downtown high-rise — is an act of rebellion against both pillars simultaneously. Every vegetable you grow is a vegetable that didn't pass through the industrial food system, which means it's a vegetable that didn't deposit the chemical residue that becomes the inflammation that becomes the chronic condition that becomes the recurring revenue for Sick Care.
Exercise as medicine. The leading causes of death in America — heart disease, type 2 diabetes, many cancers — have exercise as a frontline preventive measure more effective than most pharmaceuticals. This is not alternative medicine. This is the medical establishment's own research, published in its own journals, by its own scientists. Exercise works. And the system cannot charge you for it. There is no billing code for "went for a run." There is no copay for twenty-two minutes at 122 beats per minute. There is no facility fee for the sidewalk. The system cannot monetize what you do for yourself, which is why the system does not promote what you do for yourself.
Mental health through physical sovereignty. Callback to Part 2 of Can You Take Shit? — the boxing, the Krav Maga, the Tai Chi. The training that makes you feel safe. The humble confidence that changes how you move through the world. Physical competence reduces anxiety. Physical competence reduces depression. Physical competence reduces the stress-related illness that the Health Care pillar would otherwise treat with SSRIs and therapy billed at $250 an hour. These are health outcomes the system cannot sell you, because you built them yourself, with your own body, in your own time.
The knowledge gap as control. Nutritional literacy, exercise science, basic anatomy, how to read a blood panel — these are not taught in schools. That's an Education callback to "The Other Seven," and it's not accidental. An informed patient does not ask fewer questions. An informed patient asks more questions. An informed patient rejects unnecessary procedures. An informed patient says, "My A1C is 5.4, my CRP is under 1, my lipid panel is clean — I don't need the statin." The institution does not want informed patients. It wants compliant ones. Your ignorance about your own body is their revenue model.
The shit you take to exit.
Direct Primary Care. A monthly membership — $50 to $150 — that gives you unlimited primary care visits, no insurance middleman, no copay, no billing labyrinth. Your doctor works for you, not for the insurance company. The shit: DPC doesn't cover specialists, hospitals, or catastrophic events. You still need a catastrophic-only insurance plan for the big stuff — the $200/month plan with the $10,000 deductible that you hope you never use. But for routine care, DPC removes the extraction layer entirely. Your doctor has 400 patients instead of 2,400. She knows your name. She has time. The visit isn't a billable event — it's a conversation.
Health Sharing Ministries. Community-based cost-sharing as an alternative to insurance. Members pay into a shared pool; when someone has a medical expense, the pool covers it. The shit: most require religious affiliation, many exclude pre-existing conditions, and there is no legal guarantee of payment — it's trust-based, not contract-based. But the monthly cost is dramatically lower than insurance, and the community accountability is real in a way that a faceless insurer's "network" never is.
Cash-pay negotiation. Many providers — more than you'd think — offer 40 to 60% discounts for cash payment at time of service. Why? Because they avoid the insurance billing administrative overhead, which consumes an estimated 30% of health care spending in this country. The shit: you have to ask, which requires knowledge the system does not advertise. You have to have cash, which requires the financial margin that the pentagram is designed to deny you. But the savings are real, and the negotiation itself is an act of sovereignty — you are pricing the service, comparing options, and paying what the thing actually costs instead of what the chargemaster says it costs.
Medical tourism. A knee replacement that costs $50,000 to $100,000 in the United States costs $10,000 to $20,000 in Mexico, Costa Rica, Thailand, or India — performed by physicians who trained at the same schools, using the same equipment, in facilities that cater to international patients and maintain accreditation standards comparable to American hospitals. The shit: travel, recovery away from home, variable quality control across providers, and limited legal recourse if something goes wrong. But the math is undeniable. The chargemaster doesn't apply outside the chargemaster's jurisdiction.
Self-education. Learn your body. Understand your bloodwork. Know what A1C means, what CRP indicates, what your lipid panel is telling you about the next five years of your life. Callback to Can You Take Shit?, Part 4: Read for your path. The county clerk reads about county bylaws. You read about your own biology. One book a year about your own health — about inflammation, about metabolic function, about sleep science, about the gut microbiome. Not because you're going to replace your doctor. Because you're going to understand your doctor. And understanding changes the power dynamic from supplicant-to-authority into partner-to-partner.
The prevention stack. Grow food. Exercise at 122 bpm for 22 minutes. Train to fight. Drink the cold-pressed juice — beets, ginger, turmeric, carrot, a touch of apple to sweeten. Sleep. Manage stress through deliberate boredom — callback to Seek Boredom, the fertile soil, the practice of losing focus so your mind can find itself. This is not a wellness influencer checklist. This is a survival strategy for reducing your dependency on a system that profits from your illness. Every item on this list is a horse stance. None of them get easier. You just learn to do them longer. And the cumulative effect — the body that doesn't need the system, the mind that doesn't fear the system, the person who walks into a doctor's office as a partner rather than a supplicant — that is the exit. Not total. Not absolute. But real.
The interlocking trap. You know the shape by now.
Health insurance requires employment — or direct purchase, which requires income, which requires employment. The Labor pillar feeds the Health Care pillar feeds the Labor pillar. Health outcomes are degraded by the Food pillar — the pesticides, the additives, the pathogenic inputs that create the conditions the Health Care pillar manages. Health outcomes are degraded by the Transportation pillar — the sedentary commute that produces the obesity and the hypertension that the Health Care pillar bills for. Medical debt is the number one cause of personal bankruptcy in the United States — the Health Care pillar feeding the Finance pillar, which feeds the Housing pillar when the bankruptcy takes the house, which feeds the Transportation pillar when the address changes and the commute lengthens.
Energy is required for medical equipment, climate control during recovery, medication refrigeration. If you took the Energy exit from Part 1 and you're off-grid, your backup power systems are not convenience — they are the line between the Health Care pillar and something much worse.
The pentagram holds.
But here's the thing about the Health Care pillar that makes it different from Energy and Transportation: the exit is inside you.
The Energy exit requires hardware — solar panels, batteries, generators. The Transportation exit requires geography — live near work, own a bicycle, restructure your relationship with distance. These are external changes. They cost money. They require infrastructure.
The Health Care exit starts with a pair of running shoes and a tomato seed. It starts with twenty-two minutes and a heartbeat. It starts with a book about your own blood. The barrier is not financial, not structural, not geographic. The barrier is knowledge and discipline — the two things the system most needs you to lack.
You don't need permission to go for a run. You don't need a prescription to grow a vegetable. You don't need a referral to read a book about your own body. You don't need a prior authorization to stop eating the thing that's making you sick.
The exits are small. Some of them are daily. None of them are glamorous. But they are the most personally sovereign exits in the entire pentagram, because they depend on nothing except you.
And the institution knows it. That's why nutritional literacy isn't taught in schools. That's why exercise has no billing code. That's why the system calls itself Health Care instead of Sick Care — because if you saw the name clearly, you'd see the exit clearly, and the exit is the one thing they can't meter, can't charge for, and can't take away.
Were your exits impossible, they would not need to hide them.
Next: Part 4 — The Mortgage. How they sold you a box and called it the American Dream.
F. Tronboll III
Share