The U.S. employer‑based health insurance system is structurally misaligned with the interests of patients and employers. Costs rise faster than wages, care is fragmented, and decision‑making is outsourced to opaque insurance entities whose incentives are misaligned with patient outcomes. Employers pay enormous premiums yet still lose productivity to administrative friction, delayed care, and employee burnout navigating the system.
Keepwell Health Union proposes a nonprofit healthcare cooperative that replaces traditional insurance for routine and preventive care with a membership‑based, fiduciary‑driven model. The cooperative acts in the patient’s best interest, coordinates care, negotiates pricing, and only relies on external insurance for catastrophic coverage. The result: lower monthly costs, dramatically improved access, and a system that feels human again.
This document lays out the problem, the solution, and a realistic pilot plan for launching a San Francisco clinic serving local employers.
The modern U.S. health insurance system did not evolve to maximize health outcomes. It evolved to manage financial risk at scale, and over time that purpose quietly displaced the human one. What we now call “health insurance” is largely an administrative and financial optimization layer sitting between patients and care.
At its core, the system rewards insurers for controlling utilization rather than improving health. Every denied claim, narrowed network, or delayed authorization reduces short‑term cost exposure. None of those actions improve patient outcomes, yet they are structurally incentivized.
For employers, this creates a steady drumbeat of frustration. Premiums rise every year—often far faster than wages—while the actual experience for employees degrades. HR departments become intermediaries for disputes they cannot resolve. Healthcare spend becomes a tax on growth, hiring, and compensation rather than a true benefit.
Employees experience the system as confusing and adversarial. Coverage is opaque, bills arrive months later, and care is fragmented across uncoordinated providers. Preventive care is nominally covered but practically discouraged through access friction and time cost. As a result, many people delay care until issues are acute and expensive.
The systemic outcome is reactive medicine delivered through burned‑out clinicians inside a system optimized for billing codes, not health. Costs soar, satisfaction plummets, and trust erodes.
Keepwell Health Union starts from a simple inversion: instead of asking how to insure sickness cheaply, it asks how to keep people well efficiently.
The proposed model replaces traditional insurance for the majority of everyday healthcare with a membership‑based cooperative. Members—and by extension their employers—pay a predictable monthly fee that directly funds care delivery, coordination, and advocacy. Insurance is reserved for what it does best: rare, catastrophic, high‑cost events.
This structure dramatically simplifies the system. Members gain direct access to primary care without the psychological friction of wondering whether a visit is “worth it.” Care teams are empowered to spend time on prevention, chronic condition management, and early intervention. Employers receive a benefit that actually works and a cost curve that flattens.
The cooperative model is essential. Keepwell is not a venture‑backed entity seeking utilization margins or exit multiples. It is designed to operate at cost, reinvesting any surplus into expanded services, lower member fees, or improved access.
A defining feature of Keepwell Health Union is its fiduciary posture toward members.
In financial services, a fiduciary is legally and ethically obligated to act in the client’s best interest. Healthcare rarely operates under this standard. Providers are paid per service, insurers profit from restriction, and patients are left to navigate competing incentives.
Keepwell adopts a fiduciary approach by design. It does not receive commissions from insurers, rebates from pharmaceutical companies, or incentives tied to utilization reduction. Decisions about care are driven by outcomes, long‑term health, and member wellbeing.
This changes behavior immediately. Care teams are encouraged to solve problems early, recommend appropriate diagnostics without fear of denial battles, and coordinate across providers because doing so reduces long‑term cost and suffering.
Keepwell is not anti‑insurance; it is anti‑misuse of insurance.
Insurance functions best when it protects against low‑probability, high‑impact events. House fires are insured. Oil changes are not. Modern healthcare has inverted this logic, forcing insurance into every routine interaction.
Under the Keepwell model, the cooperative directly covers primary care, preventive services, chronic condition management, diagnostics, and care coordination. These services are predictable, manageable, and dramatically cheaper when handled directly.
External insurance remains in place for hospitalization, surgery, trauma, and complex specialty care. This functions similarly to reinsurance in finance: catastrophic protection layered on top of a stable, well‑managed base.
The result is lower premiums, fewer claims, and far less friction for everyone involved.
The pilot clinic staffing model is intentionally conservative. The goal is not to maximize patient throughput but to deliver high‑quality, sustainable care.
Two primary care physicians form the clinical backbone, supported by nurse practitioners or physician assistants who expand access and continuity. Medical assistants handle rooming, vitals, and routine workflows, allowing clinicians to focus on care rather than logistics.
Equally important are care navigators and patient advocates. These roles replace the traditional insurance maze with human guidance. They coordinate referrals, explain options, track follow‑ups, and ensure nothing falls through the cracks.
A clinic operations manager oversees day‑to‑day functioning, compliance, and vendor relationships, while front‑desk and member services staff provide a welcoming, responsive entry point. Administrative, billing, and IT functions are initially handled through fractional or part‑time support to control early costs.
This staffing mix supports lower patient panels, longer visits, and a healthier work environment—key to avoiding burnout and turnover.
Estimated legal/compliance setup: $50,000–$75,000
The following tables are intentionally explicit. Healthcare plans often fail credibility tests because the numbers feel abstract or hidden. These are concrete, conservative estimates designed to survive scrutiny.
| Category | Description | Estimated Cost |
|---|---|---|
| Legal & Compliance | Nonprofit formation, clinic licensing, HIPAA, policies | $50,000 – $75,000 |
| Clinic Buildout | Construction, exam rooms, plumbing, signage | $75,000 – $125,000 |
| Medical Equipment | Exam tables, vitals, EKG, basic diagnostics | $75,000 |
| Furniture & Fixtures | Waiting room, offices, staff areas | $25,000 |
| IT Systems Setup | EHR onboarding, security, devices | $25,000 |
| Pre-Launch Staffing | Hiring, training, credentialing runway | $50,000 |
Estimated Startup Total: $300,000 – $375,000
| Category | Annual Cost (Estimate) |
|---|---|
| Staffing | $1,980,000 |
| Clinic Rent & Utilities | $300,000 |
| Medical Supplies | $120,000 |
| IT Systems & Software | $60,000 |
| Insurance & Compliance | $120,000 |
| Misc. & Contingency | $120,000 |
Estimated Annual Operating Cost: ~$2.7M
This model assumes intentionally smaller patient panels than traditional primary care.
| Role / Resource | Quantity per 1,000 Members |
|---|---|
| Primary Care Physicians | 2 |
| Nurse Practitioners / PAs | 2 |
| Medical Assistants | 2 |
| Care Navigators / Advocates | 2 |
| Clinic Operations Manager | 1 |
| Front Desk / Member Services | 1 |
| Clinic Space | 2,500–3,000 sq ft |
| Cost Category | Annual Cost |
|---|---|
| Staffing | ~$2.0M |
| Facility | ~$300k |
| Systems & Supplies | ~$300k |
Total Cost per 1,000 Members: ~$2.6M – $2.7M annually
At a membership fee of $450 per member per month, 1,000 members generate ~$5.4M annually, leaving significant margin for catastrophic coverage, reserves, service expansion, and fee reduction.
Once the core clinic is operational, the model naturally expands into adjacent services that increase value without distorting incentives.
Monthly in‑office hours at employer locations reduce friction even further. Employees can address routine issues without leaving work, improving utilization of preventive care and reducing lost productivity.
Prescription management offers another significant opportunity. By working directly with pharmacies and wholesalers, Keepwell can provide transparent pricing, bulk purchasing, and mail‑order fulfillment. This eliminates rebate games and surprises at the counter.
Over time, de‑identified aggregate health trends can be shared with employers, offering insight into preventive opportunities, chronic condition prevalence, and absenteeism drivers—without compromising individual privacy.
Specialist, lab, and imaging partnerships round out the ecosystem. Pre‑negotiated, transparent pricing allows members to make informed decisions and keeps downstream costs under control.
Healthcare is regulated, complex, and slow to change. Any credible plan must acknowledge risk.
Regulatory and compliance risk is mitigated through early engagement with experienced healthcare legal counsel and adherence to established clinic models. This is not a regulatory gray‑area experiment.
Adoption risk is addressed by focusing initial enrollment through employers rather than individual consumers. Employers act as trusted intermediaries and enrollment accelerants.
Clinician burnout—a common failure point in healthcare startups—is mitigated by design: lower patient loads, longer visits, and administrative support are not perks but structural requirements.
Finally, scaling risk is controlled by intention. The pilot is designed to be proven, documented, and then replicated—not prematurely expanded.
This is not theoretical. Variations of this model already work — this is a thoughtful, integrated execution.
One of the strongest arguments for Keepwell Health Union is not ideological—it is mathematical. Employer-sponsored health insurance has grown dramatically more expensive over the past two decades while delivering diminishing perceived value to both employers and employees.
The following comparison illustrates a conservative, illustrative trend for a typical employer-sponsored plan versus a Keepwell-style cooperative model.
| Year | Traditional Employer Plan (Total Cost) | Employer Share | Employee Share | Keepwell Health Union (Total Cost) | Employer Share | Employee Share |
|---|---|---|---|---|---|---|
| Year 1 | $21,000 | $15,750 | $5,250 | $5,400 | $5,400 | $0 |
| Year 2 | $22,470 (+7%) | $16,850 | $5,620 | $5,400 | $5,400 | $0 |
| Year 3 | $24,040 (+7%) | $18,030 | $6,010 | $5,400 | $5,400 | $0 |
| Year 4 | $25,720 (+7%) | $19,290 | $6,430 | $5,400 | $5,400 | $0 |
| Year 5 | $27,520 (+7%) | $20,640 | $6,880 | $5,400 | $5,400 | $0 |
Assumptions: Traditional plans increase at ~7% annually. Keepwell pricing remains stable due to direct care delivery and limited insurance exposure.
| Model | Employer Total (5 Years) | Employee Total (5 Years) | Combined Total |
|---|---|---|---|
| Traditional Insurance | ~$90,560 | ~$30,190 | ~$120,750 |
| Keepwell Health Union | $27,000 | $0 | $27,000 |
Over five years, the traditional model costs more than 4× as much per employee while still exposing employees to out-of-pocket premiums, deductibles, and care friction.
The chart below visualizes how employer-sponsored insurance compounds over time compared to a stable cooperative model. The widening gap is the story.
This visualization intentionally emphasizes stability versus compounding escalation. One curve grows because it must. The other stays flat because it is designed to.
This delta is not theoretical savings—it is real capital that employers can redirect toward wages, hiring, retention, or business growth, while employees experience simpler, faster access to care.
Keepwell Health Union is a pragmatic reset of healthcare delivery — simpler, cheaper, and aligned with reality.