Big Health Care is ending a terrible year. Is anyone happy with this business?

Health care companies are ending 2024 in the hot seat. Yet some of the pressures they're facing have been mounting all year — or longer.

This month's killing of UnitedHealthcare CEO Brian Thompson thrust his company, and his industry, into the spotlight. It also sparked widespread consumer reckoning over denied claims and the high costs of care in the United States, where health care is the most expensive in the world. Now lawmakers on both sides of the political aisle are stepping up their scrutiny of the industry.

But even before Thompson's shocking death on a New York City street, and its ongoing aftermath, the business of Big Health Care was having a rocky year. Costs are up, profits are down, top executives have lost their jobs, and investors are selling off the shares.

This industry, which affects the lives and very well-being of the entire country, has been getting relentlessly bigger for years. Industry executives say that this growth allows big companies to offer a wider array of low-cost health care services to more people, while critics and consumer advocates say that the size and scale of these companies makes them opaque and expensive, and ultimately leads to worse outcomes for patients.

Authorities say the suspect in Thompson's killing, 26-year-old Luigi Mangione, appeared to share such critiques; he was found in possession of a notebook that "contained several handwritten pages that express hostility towards the health insurance industry and wealthy executives in particular," according to the federal charging document filed by the FBI.

For better or worse, the for-profit industry's size and scale seems here to stay. Health care spending accounted for $4.9 trillion last year – or almost 20% of the U.S. economy – as well as some of the world's largest companies. Thompson ran the largest U.S. health insurer, UnitedHealthcare, for a parent company that is even bigger: the overall UnitedHealth Group parent company is also the country's top employer of doctors and the fourth-largest U.S. company by revenues.

"These massive organizations do everything under the sun, almost, when it comes to health care. They've got their tentacles everywhere," says Lovisa Gustafsson of the Commonwealth Fund, a health care research nonprofit.

Yet for all the power they wield, and all the money they make, these companies — and their investors — also have their discontents. CVS Health, the conglomerate that owns Aetna and is the 10th-largest company in the world, abruptly replaced CEO Karen Lynch in October. That same month, UnitedHealth unveiled a weaker-than-expected business forecast for 2025. Bothcompanies, and their competitors, are facing rising costs in the Medicare Advantage businesses that were once seen as money-makers.

These companies are still profitable. But because their profits aren't growing, their investors aren't happy: Shares of UnitedHealth, CVS Health, and other large health care conglomerates have fallen this year, while the overall market thrives.

"It's been a tough year," says Julie Utterback, a health care analyst at Morningstar.

Congress and President-elect Trump focus on Big Health Care

Next year may be tougher – including in Washington. Last week, Democratic Sen. Elizabeth Warren of Massachusetts and Republican Sen. Josh Hawley of Missouri introduced legislation that would break up large health care conglomerates, including UnitedHealth, the parent company where Brian Thompson was an executive.

President-elect Donald Trump chimed in this week, to criticize the pharmacy benefit managers owned by these big conglomerates.

These controversial businesses essentially control what Americans pay for their prescriptions. The three largest benefit managers are owned by UnitedHealth, CVS, and Cigna – and together they process 80% of U.S. prescriptions.

"They don't do anything, except they're a middleman," Trump said during a press conference Monday. "We're going to knock out the middleman."

UnitedHealth and Cigna declined to comment for this article. A spokesperson for CVS Health said via email that "we believe in the integrated value our businesses deliver" and that, regarding lawmakers' recent comments on pharmacy benefits managers, "We are proud of our continued work to make prescription drugs more affordable in the United States."

Pharmacy benefit managers have been widelycriticized – and scrutinized by the U.S. government – for years. This fall, the Federal Trade Commission sued the three largest managers, alleging that they engage in "anticompetitive and unfair rebating practices that have artificially inflated the list price of insulin drugs." (The PBMs then counter-sued the FTC.)

And it remains to be seen what action the next Trump administration or incoming Congress may actually take.

But Morningstar's Utterback said that the increased regulatory scrutiny, stoked by this month's public backlash, is a mounting worry for healthcare investors.

"A month or so ago, I wasn't really that concerned," she said. But "what people and most investors are really focusing on is what could come down the regulation pipeline."

Everyone agrees: U.S. health care is broken

Investors obviously have very different motivations – and complaints – than the tens of millions of patients who can't get or can't afford health care in the United States.

But it's striking how even those who are making money from this large and powerful business are increasingly unhappy with it.

Even top industry executives acknowledge this systemic dysfunction – to a point.

"We understand and share the desire to build a health care system that works better for everyone," UnitedHealth CEO Andrew Witty wrote in a New York Times op-ed last week.

His headline? "The health care system is flawed. Let's fix it."