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Nearly $400 billion in revenue.

In January, UnitedHealth Group (UHG) released its . It paints a vivid picture -- not just of financial success and wealth transfers -- but of a healthcare Goliath seemingly towering over and controlling all the levers of the industry and perhaps even the government.

In 2023, UHG raked in a jaw-dropping , with $5.5 billion in the fourth quarter alone. Revenue? It was up by 14.6% to an incredible $371.6 billion. To put that in context, UHG's revenues are higher than the of Finland, the Czech Republic, Hong Kong, Greece, and another 132 regions or countries worldwide.

Alongside its year-end financial report, UHG announced it expects between $400 billion and $403 billion in revenue in 2024.

Impressive? Absolutely. But is UHG's empire good for the healthcare system, clinicians, and patients? Here is where it gets interesting -- or concerning, depending on your view.

This financial windfall has come via rewriting healthcare industry practices through vertical integration. With its healthcare services provider Optum and other acquisitions, vertical integration has allowed UHG to essentially be a value-chain monopoly, controlling everything from health insurance to medical services to healthcare data to pharmaceuticals.

Vertical integration might sound benign until you illustrate the result: ; fewer insurance choices for providers, employers, and patients; ; and profits that could be put to better use. It is a model that raises questions: Are we looking at healthcare for many, or "wealthcare" for shareholders and insurance executives?

UHG is not alone. Five other big-name payers are : CVS Health, Cigna Healthcare, Humana, Elevance Health, and . UHG just happens to be the biggest.

Is this the healthcare future we want? One where giants like UHG dictate terms of employment for physicians (right now, the company of all U.S. physicians) and create dubious algorithms for patient care decisions? (A filed last fall alleged UHG illegally used artificial intelligence to deny rehabilitative care to Medicare Advantage patients. Other similar lawsuits alleging denial of care have also been filed against , , and .)

Where have the regulators been, like the Federal Trade Commission, the Department of Justice (DOJ), or the new HHS chief competition officer who is supposed to coordinate, identify, and elevate opportunities to promote competition in healthcare markets?

UHG is projected to have more than $400 billion in revenue for 2024, and if its profit margins continue to track with its revenues, its profits could top $26 billion. (To be clear, high revenues do not equal profits. There are many cases where high-revenue companies make very little. While a 6.5% profit margin sounds relatively low, it is the volume of money and the magnitude of money that makes the potential impact and control staggering.)

In a free-market economy, companies and their shareholders are obviously entitled to their profits. (Whether entities like UHG could do good with their profits is another story. Could they, for example, take some of the $5 billion they made in the fourth quarter of 2023 to help pay off student debt for their physicians? Could they improve innovation or reimbursement rates? Could they reduce premium costs for their customers or costs for employers?) But UHG did not become the giant it is today without distortions in the market, and this should concern liberals and conservatives alike.

UHG became the behemoth it is because it has been able to buy up companies like Optum, DaVita Medical Group, and even The Advisory Board without so much as a blink of an eye from regulators. Consider this fact: UHG lobbying expenses ballooned between 1998 and 2023. (It spent less than $1 million on lobbying in 1998.) In just one year, from 2022 to 2023, its government relations spending went from $6.4 million to almost $11 million.

Meanwhile, regulators have blocked the mergers of and physician practices because of antitrust concerns.

It appears, however, that after years of apparent somnolence, the DOJ may have awakened, launching an focused on the relationships between United Healthcare's insurance unit and subsidiary Optum's healthcare services arm. Depending on the findings, the implications for industry consolidation and vertical integration could be significant.

Quite simply: for diehard capitalists, what we are seeing in the insurance ecosystem is not the free market. It's a guided or controlled market with growing market distortions where years of policy have granted winners and losers. Which is why, for the good of patients, providers, and the economy as a whole, Washington regulators need to wake up and enforce anti-competitive practices.

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