Why These Healthcare Giants Could Face Pressure From Startups

U.S. healthcare is a $5 trillion machine, but much of it runs on decades-old infrastructure – manual billing, opaque pricing, and convoluted middle layers. As costs spiral and employers look for better value, a new class of infrastructure-first healthcare companies is emerging that offer alternatives that are leaner, more transparent, and built for the digital age.

The first wave of digital health was all about apps – tools to boost patient engagement or improve specific conditions. But today's innovators are focused on the core infrastructure that makes healthcare work. That means rebuilding the systems behind the scenes, like analytics, payments, pharmacy services, and provider networks.

Instead of trying to fix the old system, these companies are creating entirely new ones.

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The Infrastructure Uprising

Innovative startups are reshaping the healthcare landscape by developing integrated platforms that streamline healthcare infrastructure. These new systems emphasize real-time payments, enhanced analytics, transparent pharmacy benefit models, precision medicine enablement, and direct provider contracting.

For instance, several companies are addressing specific structural inefficiencies — some focus on eliminating deductibles and copays through real-time transaction systems; others are aggregating fragmented patient data to support personalized treatment planning. Platforms like Nomi Health, xCures, Transcarent, Carrum Health, Firefly Health, and SuperTruth are often cited in industry discussions as examples of this shift, offering models that diverge sharply from traditional insurance architecture.

This movement isn't about tweaking legacy systems but replacing them entirely. The focus here is on transparency, speed, and patient-specific outcomes. As a result, many of these companies are gaining attention among self-insured employers, rural health agencies, and clinical research groups looking for more agile infrastructure.

Public Giants Under Pressure

The rise of these challengers is placing new pressure on publicly traded incumbents, whose business models are deeply embedded in the traditional layers of healthcare.

UnitedHealth Group (UNH)

The dominant force in U.S. healthcare, UnitedHealth generated more than $370 billion in revenue in 2024 through UnitedHealthcare and Optum. While Optum has become a healthcare empire—managing data, providers, and pharmacy—its sheer size has drawn regulatory attention. Critics argue that vertical integration has made the system more opaque and less competitive.

CVS Health (CVS)

CVS's model combines Aetna (insurance), Caremark (PBM), and its growing clinic footprint. But it faces rising skepticism over pharmacy benefit management practices and high administrative costs. Employers are increasingly exploring transparent PBM alternatives and care bundles that don't involve navigating complex rebate ecosystems.

Cigna Group (CI)

Cigna has leaned into a services strategy with Evernorth, encompassing Express Scripts, virtual care, and analytics. While it delivers convenience, it still operates within a traditional insurance wrapper. That model is being questioned by employers looking to escape the cycle of annual renewals and opaque claims processes.

Elevance Health (ELV) and Humana (HUM)

These two players dominate government-backed plans, particularly Medicare Advantage. But with increasing regulatory scrutiny around risk scoring and plan design, their long-term growth may face headwinds. Meanwhile, infrastructure-first startups are forming partnerships with public agencies to bring modern tech and rapid deployment to Medicaid and rural health programs.

The Investment Lens

While most of these startups are private, their influence is being felt across the public markets. Investors should watch:

• Margin erosion and pricing pressure at legacy payers
• The accelerating shift of self-insured employers toward platform solutions
• The emergence of transparent, same-day payment systems
• Increased demand for longitudinal clinical data and real-world evidence platforms like xCures
  

It's likely that the real action is no longer in point solutions but who owns the infrastructure. That's where control, value, and scale intersect.

Bottom Line: Infrastructure is the Next Frontier

What comes after digital health apps? System control.

As employers, health systems, and public entities look to contain costs and improve outcomes, the next generation of healthcare leaders will be those who offer the infrastructure – not just the interface. From real-time payments to intelligent treatment guidance, these challengers are building the scaffolding for a smarter, more responsive healthcare economy.

The incumbents may still dominate the headlines, but if control is the next currency in healthcare, the tide is turning fast.