US healthcare needs a revolution, not innovation.

US healthcare has accumulated a century of regulation and technical debt that no amount of AI will fix. We need to reform the system from first principles to have a chance of fixing it.

I have been a life‑long follower of Quantified Self and I never thought much about access to healthcare because I rarely interact with the system. Most of my healthcare experience has been me doing regular biometric tests out of pure curiosity and analyzing them with doctor friends or myself using AI. I never had a problem paying for these costs out‑of‑pocket since they were cheap in Europe. I also know that I will always have access to the doctors should I need it. Living in a single‑payer healthcare system (universal coverage provided by the government) you never have to think about how much something will cost you. If you’re feeling sick, you try to find the first doctor who is available. Healthcare is not supposed to be a source of stress. In the U.S., however, it’s a real source of nightmares.

That illusion of safety shattered the night my friend called me from New York.

To illustrate that with a story, I will tell you what happened to my friend Dom. He has a history of heart arrhythmia and went through treatment last year in Hungary, where he is from. He spends a few months each year in the U.S. and has travel insurance just for emergencies. He is super active and very health‑conscious, so he rarely sees a doctor. When his heart started racing, he called me and said, “I need the ER—how do I avoid bankruptcy?” not “Where’s the nearest cardiac unit?” I was scared for him, then angry that cost anxiety came before care. Domo’s story isn’t an outlier; it’s a symptom of a badly aligned market.

Why is care so expensive in the US?

Salaries are high, but not twice those of other Western nations. In theory, private competition should push prices down. Instead, every layer is mis‑aligned. Employers choose plans that must cover government‑mandated essential benefits. Insurers must price policies without knowing individual risk, so younger, healthier workers subsidize older, sicker ones. Employers rely on brokers who steer them toward plans that maximize the broker’s commission. Nobody—employer, broker, or insurer—feels true accountability for cost or outcomes.

Given the price tag, you would at least expect world‑class service. You don’t get it.

I learned the same misalignment first‑hand at an urgent‑care clinic in SoHo. One winter morning I woke with piercing ear pain, searched for the closest clinic, and called to confirm they “accepted all insurance.” Fifteen minutes later I flashed my card—only to hear, “Marketplace plans aren’t in network.” My company was paying $1,600 a month for the top‑tier policy, but none of that mattered.

I stayed anyway, desperate for antibiotics. After a brief look in my ear, the doctor veered into mood questions, vaccination upsells, and back‑pain screenings. Five minutes later I walked out. Months afterward I discovered charges for each unnecessary question—$15 for one antibiotic pill, $30 to swallow it in the office. The fee‑for‑service model incentivizes more CPT codes, not better outcomes.

Prevention should be valued—yet it isn’t

Ironically, I’m the type of patient insurers should court—obsessed with prevention. I tested Oura, Supersapiens CGM, EightSleep, Levels, gut‑biome kits, regular bloodwork, VO₂‑max labs—you name it. Thanks to diet and exercise, my reactive medical costs stay under $1,000 a year. But insurers profit from a member for only 1.5 years on average, the “actuarial risk horizon.” They have no financial reason to fund long‑term prevention when I could switch plans next year. Employers’ horizon is only four years. The only stakeholder rewarded for staying healthy is me—yet I can’t pick a plan that rewards me back.

Trying to fix it for my own team

Even when I tried to solve this for my team, the system punished us. My last startup used individual coverage health‑reimbursement arrangements (ICHRA), an allowance model that lets employees buy any Affordable Care Act (ACA) marketplace plan and keep leftover dollars for other health expenses. After hours of research I chose an Anthem platinum plan with a $600 deductible. I learned the hard way that marketplace plans primarily serve lower‑income Americans and are price‑capped by state committees. To hit those caps, insurers shrink provider networks.

Healthy employees “hack” ICHRA by picking the cheapest bronze plan they never intend to use, pocketing more allowance dollars. But that still leaves a $10k deductible wall if anything bad happens. If this is the peak of employer innovation, the outlook is grim.

To understand why every modern fix feels like a band‑aid, we have to rewind to 1942. Roosevelt froze wages during WWII, so employers dangled health coverage as a perk. The 1954 Revenue Act made employer‑sponsored insurance tax‑free, cementing the link between job and coverage.

Commercial health insurance grew with minimal regulation. High‑risk individuals paid higher premiums, so the uninsured rate hit 15%, and medical bills became America’s top cause of bankruptcy. Over time, drugs, procedures, and administrative layers inflated costs; admin alone now adds ~25% to every bill.

In 2010 the Affordable Care Act banned risk‑based pricing, created subsidized exchanges, imposed essential‑benefit rules, and capped insurers’ overhead at 15% of premiums. Premiums and benefits were regulated; underlying prices were not. Result: a “private” market with government rules and runaway costs.

All those layers culminate in today’s unsustainable math. Marketplace networks keep shrinking while per‑capita spend tops $14k—2‑3 × other rich nations. Medicare and Medicaid now eat 21% of the federal budget. Fifteen years after the ACA, the uninsured rate has inched from 15% to 11%, and medical debt still drives most bankruptcies. Something has to give.

Is there a better model?

Many Americans point to Canada or Europe’s single‑payer systems, but converting the U.S. wholesale is fiscally and politically improbable. If the U.S. seems trapped, look at how Singapore escaped a similar bind.

Singapore spends one‑quarter what America spends per person yet boasts world‑leading life expectancy and a mostly private delivery system. Employers pay 10% of salary into mandatory health‑savings accounts (HSAs). Prices are transparent, and patients pay cash from their HSA, creating downward pressure on providers. Public hospitals are subsidized so no one is denied basic care, while a universal insurance layer handles catastrophic costs.

Why am I telling you this? The U.S. already runs a parallel idea—the 401(k). Make HSAs universal and portable, push routine spending to cash, and market forces will reward prevention. Larger HSA balances become a retirement asset, directly aligning health and wealth.

Enter Rivendell

Rivendell borrows Singapore’s two‑tier logic—cash‑driven prevention plus catastrophic back‑stop—and adapts it to U.S. regulations. I’m not running for president, but I am tackling the biggest problem of our generation by building this company. Our mission: give every American real incentives for preventive care, while shielding them from financial ruin. If that vision excites you, join us. We need missionaries and artists alike. Let’s build the system America deserves.