How We Got Here: Chapter 7

how we got here Jul 07, 2026

The Business of Being Sick

Estimated read time: 12 minutes

Last week we traced how modern medicine became extraordinarily good at treating disease while gradually placing less emphasis on understanding how health is created in the first place. By the end of that article, one question kept following me. If prevention genuinely works, and the evidence that it does is not particularly controversial, why does so much of our healthcare economy still revolve around treating chronic disease after it develops rather than preventing it?

To answer that, I had to stop thinking about healthcare as a profession and start thinking about it as an industry.

In 2023, Americans spent nearly five trillion dollars on healthcare. That's roughly fourteen thousand five hundred dollars for every man, woman, and child in the country, accounting for about seventeen percent of the entire U.S. economy. If the American healthcare system were its own country, its economy would rank among the largest on Earth.

That money supports extraordinary hospitals, groundbreaking research, life-saving medications, and millions of people who dedicate their careers to improving and saving lives. None of that is the problem. But industries respond to incentives. And once I started thinking about healthcare as both a profession and an industry at the same time, I found myself asking very different questions.

An analogy kept pulling at me while sitting with all of this research. Watch the coverage any time a major wildfire breaks out in California. The firefighters are extraordinary. The equipment is advanced. The coordination is remarkable. Thousands of people mobilize at enormous cost to contain something that is actively destroying everything in its path. Nobody watching that coverage questions whether we need firefighters. Of course we do. Fires are going to happen and when they do you need people who know how to fight them.

But at some point, if the fires keep getting bigger and more frequent every single year, you have to start asking a different question. Not whether the firefighters are doing their job well. They clearly are. The question is why there are so many fires in the first place. Why is the land this dry. Why are these conditions getting worse. What would it actually take to address the root cause rather than just getting better and better at responding to the damage after it's already happening.

That's roughly where we are with chronic disease.

According to the CDC, ninety percent of annual healthcare spending in the United States is tied to people living with chronic physical or mental health conditions. Not broken bones, not emergency surgeries, not appendicitis. Six in ten American adults now live with at least one chronic disease. Four in ten live with two or more. Heart disease, Type 2 diabetes, obesity, hypertension, arthritis, chronic kidney disease, anxiety, depression. These aren't rare diagnoses affecting a small slice of the population. They've become so common that many people simply assume they're a normal part of getting older.

That assumption might be one of the most consequential things we've quietly accepted.

A broken wrist is expensive but finite. Emergency visit, X-ray, maybe a follow-up, and eventually life moves on. Chronic disease is different. Someone diagnosed with Type 2 diabetes at fifty may require physician visits, laboratory testing, medications, specialist referrals, eye exams, foot care, and treatment for complications for the next thirty or forty years. These aren't one-time interactions with the healthcare system. They're ongoing relationships measured in decades.

Without anyone designing it this way, chronic disease became the economic engine of modern healthcare. The longer a condition persists, the more appointments get scheduled, the more prescriptions get filled, the more tests get ordered. When you follow the money through a five-trillion-dollar industry, chronic disease appears at the center of the story again and again.

Once you see that, it's hard to unsee. Hospitals don't grow because more people stay healthy. Pharmaceutical companies don't build revenue forecasts around prescriptions that never get filled. None of that requires anyone to be malicious. It's simply the economic reality of a system whose greatest financial activity begins after disease already exists. That's what I mean by the business of being sick. Not that anyone wants people to suffer, but that an enormous amount of economic activity depends on people entering the system and staying there.

Prevention doesn't fit that model. When it works, almost nothing happens. You can't bill for the surgery that was never needed. You can't count the heart attack that never happened. Success shows up as an ordinary Tuesday, and ordinary Tuesdays don't generate quarterly earnings reports. Treatment creates a transaction. Prevention creates an absence. And healthcare has become extraordinarily good at paying for transactions.

The same pattern played out twice in my lifetime, with different diseases, different drugs, and the same story underneath.

The first version goes back to the heart disease epidemic. By the 1980s, cardiovascular disease had become the leading cause of death in America. Physicians needed reliable tools to manage cholesterol, and statins arrived as the answer. They were effective, scalable, and could be prescribed at a routine office visit and refilled at any pharmacy. Within a few years, statins became some of the most widely prescribed medications in history.

What rarely made the same headlines was the parallel evidence building around lifestyle. Regular exercise, improved nutrition, smoking cessation, and stress reduction were all shown to meaningfully reduce cardiovascular risk, in some cases comparably to medication for certain patients. Those interventions required no patent, no manufacturing, no distribution network, and generated relatively little revenue. Statins became a multi-billion dollar category. Lifestyle medicine stayed a conversation that happened mostly at the margins.

I wasn't looking for problems with statins when I started digging into this. I was just trying to understand what happened in the decades after they became one of the most prescribed medications in America. That's when I kept running into a body of research I hadn't expected to find.

Long-term statin use has been consistently associated with an increased risk of developing Type 2 diabetes. Multiple studies and meta-analyses have found that extended statin treatment impairs insulin sensitivity and can interfere with the pancreas's ability to secrete insulin properly. In some research, long-term users show a significantly elevated risk of new-onset diabetes compared to non-users, with the risk growing alongside the dose and duration of use. A medication prescribed to reduce cardiovascular risk can, over time, increase insulin resistance, which is itself a major risk factor for cardiovascular disease. The drug may reduce one cardiovascular risk factor while introducing a separate metabolic tradeoff that most patients were never told existed.

None of that means statins don't help people. For many patients, the cardiovascular benefit is real and the tradeoff is worth it. But most people sitting across from their doctor have never had that conversation. They were told their cholesterol was high and they needed a pill. The downstream effects of that pill were rarely part of the discussion.

Obesity has been a documented public health crisis for decades. The research linking excess body weight to Type 2 diabetes, heart disease, fatty liver disease, sleep apnea, and certain cancers has been sitting in the literature for a long time. Throughout that entire period, the evidence that nutrition, movement, sleep, and stress management could meaningfully reduce obesity and its downstream effects was never particularly controversial. Lifestyle interventions worked. They were just slow, difficult to standardize, impossible to patent, and hard to build a business around.

Then GLP-1 medications arrived. Clinical trials showed meaningful weight loss, improved blood sugar control, and reduced cardiovascular risk for many patients. Almost overnight, what had been a specialized area of medicine became one of the biggest investment opportunities in modern healthcare.

What fascinated me wasn't the drugs themselves. It was watching what happened after they worked. Investors began treating obesity as one of the largest growth markets in the history of healthcare. Pharmaceutical companies raced to expand manufacturing capacity. Competitors rushed development pipelines for the next generation of compounds. Analysts started projecting trillions of dollars in future market value. Obesity had been one of the country's most visible public health problems for decades. It only became one of its biggest business opportunities once there was a product that could be patented, prescribed, manufactured at scale, and sold to a market of hundreds of millions of people. The science didn't change. The incentive structure did.

And the downstream effects? Studies now show that up to forty percent of weight lost on GLP-1 medications may come from muscle rather than fat. Patients who stop taking the medications regain an average of seventy-five to ninety percent of lost weight within a few years, because the drug was suppressing hunger signals without addressing the habits, nutrition, or metabolic health that created the problem in the first place. Research is also identifying measurable bone density loss in some users, and gastrointestinal side effects are significant enough that as many as two thirds of people stop taking the medications within a year, often before seeing lasting results.

For the right patient, managed correctly and paired with genuine lifestyle change, GLP-1 medications are a meaningful tool. But the conversation happening in most doctor's offices isn't about using the medication as a bridge toward building healthier habits. It's about the medication as the solution. And without the lifestyle piece, patients are often caught in a cycle of taking a drug indefinitely, or stopping it and regaining everything they lost.

Here's where this gets difficult to ignore.

Statins became one of the most widely prescribed medications in history during the 1980s and 1990s. Research consistently linking long-term statin use to increased insulin resistance and new-onset Type 2 diabetes started accumulating through the 1990s and 2000s. And over roughly that same period, rates of Type 2 diabetes in the United States climbed steadily. Nobody is suggesting statins caused the diabetes epidemic. The relationship between chronic disease and lifestyle is genuinely complex, and there are many factors involved. But we prescribed a medication to tens of millions of people that we now know increases their risk of developing a separate chronic disease, and that second chronic disease became the foundation of an entirely new pharmaceutical economy.

GLP-1 medications exist primarily to treat Type 2 diabetes and obesity. The patients driving that market are exactly the population that has been on long-term medications, living with metabolic dysfunction, and cycling through the healthcare system for decades. The system didn't plan that outcome. But it produced it. And now it has built a multi-billion dollar solution for a problem that the previous multi-billion dollar solution helped create.

The pattern is identical across both examples. A problem driven largely by lifestyle. A pharmaceutical solution that addresses the symptom. Downstream effects that are real but rarely discussed at the point of prescription. And a system that is structured to keep managing the condition rather than resolving it.

The more I sat with that, the less this felt like a story about any specific medication. Statins happened to illustrate one version of the pattern. GLP-1 medications illustrate another. Whatever the next major pharmaceutical breakthrough turns out to be, I'd be willing to bet the same underlying incentives will still be there. The medications change. The diseases shift. The companies evolve. But the economic structure that rewards treatment over prevention has stayed remarkably consistent across all of it.

This isn't an argument that the healthcare system is corrupt, or that physicians are deliberately keeping people sick, or that medications are always the wrong answer. That kind of thinking is too simple and the evidence doesn't support it. Most physicians genuinely care about their patients. Most researchers are genuinely trying to find better treatments.

The problem is a system that evolved to manage disease efficiently, in an era when management is exactly what the economics reward. A patient who takes a medication for thirty years and stays stable is, from the system's perspective, a success. A patient who changes their lifestyle so fundamentally that they no longer need the medication is also a success, but that outcome generates far fewer touchpoints, far fewer prescriptions, and far fewer billable interactions. One of those success stories is far easier to build a business model around than the other.

What I've watched happen over twenty years of coaching is that the people who actually turn their health around almost always do it the same way. Not by finding the right medication. Not by getting the perfect diagnosis. By slowly, imperfectly, consistently changing the way they eat, move, sleep, and manage stress. The medication might help them get started. The lifestyle is what actually changes the trajectory.

GLP-1 medications, peptides, hormone therapy, TRT, none of these things are actually new. I've worked in the health and fitness industry for twenty years. These compounds have existed in my world for a long time. Coaches, athletes, and performance-focused people have been using various combinations of them for decades. What's new isn't the science. What's new is that they've been packaged, approved, and marketed to a mass consumer audience as the answer to a lifestyle problem.

I'll be transparent here because I think it matters. I've used peptides myself to achieve a specific result. And they worked. But I'm also completely convinced they only worked the way they did because I already had everything else in place, the training, the nutrition, the sleep, the recovery habits. The peptide wasn't the thing that got me the result. It was the thing that helped me get a little further along a path I'd already been building for years. And because the lifestyle foundation was there, I was able to maintain that result after stopping. I didn't have to stay on it indefinitely. That distinction is everything.

In my experience, these compounds work best for people who have already done the lifestyle work. People who are training consistently, eating well, sleeping, managing stress, and who need a specific tool to address something the lifestyle alone hasn't fully resolved. Used in that context, alongside real behavior change, they can be genuinely useful. But most people aren't approaching them that way. Most people are approaching them as the starting point. And if you learn to lose weight on a medication without ever changing how you eat or move, you haven't learned how to be healthy. You've learned how to lose weight on a medication. The moment that medication goes away, so does everything that came with it.

I've spent enough time in this industry to have a pretty clear view of both extremes. On one side you have the coaches and practitioners who are fully bought into the system, every new pharmaceutical advancement is safe because it has FDA approval, every symptom has a corresponding prescription, trust the medicine and follow the protocol. On the other side you have people who reject all of it, no doctors, no medications, no science, only what comes from the earth. I understand both perspectives. I don't fully agree with either one.

The healthiest, most resilient people I've worked with over the years tend to live somewhere in the middle. They eat whole foods, train consistently, prioritize sleep and recovery, manage their stress, and actually enjoy their lives. But they also get their blood work done. They use their doctor for what a doctor is genuinely good at, reviewing labs, catching things early, and being there if something serious goes wrong. They treat medication as one tool among many, not as the foundation of their health. And if they do need a prescription for a period of time, they're still doing all the other things, because they understand that the lifestyle is what actually heals.

I've watched people put chronic conditions into remission through lifestyle intervention alone. I've also watched people spend years managing a disease with medication without ever meaningfully changing its trajectory. The difference, almost without exception, comes down to whether someone is using the system as a partner in their health or as a substitute for doing the work themselves.

Prescriptions are not the solution. But they're not the enemy either. They're a tool. And like any tool, what matters is the context you use them in.

The healthcare system is extraordinary at what it was designed to do. What it was never designed to do is build your health for you. That part requires something the system isn't structured to provide, which is time, accountability, and someone invested in the outcome of you actually not needing the system anymore.

Every week in this series we've looked at a different piece of the same puzzle. Food. Movement. Healthcare. Economics. None of them exist in isolation. They're all systems, and systems tend to produce exactly what they're designed to reward. If we want healthier people, we can't only keep asking how to build better treatments. We also have to start asking what kind of environment creates fewer patients in the first place.

That question, I think, is what this series has really been about all along.

We've spent the last several articles following what happened to our bodies. Food, movement, healthcare, chronic disease, and the economics underneath all of it. But somewhere along the same timeline, something else was quietly changing too.

Human attention became one of the most valuable commodities on Earth. And once that happened, an entire industry organized itself around capturing as much of it as possible, for as long as possible, by whatever means necessary.

Your distraction isn't entirely accidental.

That's next week.

I'm Coach Andy, founder of Protean Fitness. If this series is resonating with you, follow along on Instagram and LinkedIn, or join the Protean Wellness Community.

Sources:

How We Got Here: Chapter 7

The Business of Being Sick

Two Step