When Care Becomes a Casino

This is a speculative computational exercise in financial cross-pollination. It's also fairly noir—conceived while re-watching Margin Call with live US news on a second screen, punctuated by ads for trading app Robinhood and various short pharma musicals. You may wish to skip it.

A few years ago I developed a future design exercise called Money for Mars* that asked a simple question: what happens to financial instruments when you can no longer assume Earth conditions? Take a familiar tool like insurance or a mortgage, drop it into a location with 46-minute communication delays or 3.5-day orbital periods, and watch it mutate. The outcomes can be interesting, enlightening, and even connected to form ecosystems, in some cases.

The premise wasn't arbitrary. We're entering the commercial space development envelope when I first imagined the exercise in 2017, and we’re well within it now. The companies exist, the launch cadence is real, the timelines are measured in months rather than decades. Money for Mars is forward planning for the late 2020s and 2030s.

American healthcare is operating on a similar timeline—but in reverse. We're well inside the breakdown envelope. The system that sort of worked, badly, for the past decade is coming apart faster than most people realize.

The Affordable Care Act was a compromise designed to fail slowly. It preserved the employer-based system, created individual mandates without adequate enforcement, and relied on subsidies that required constant legislative renewal. The enhanced premium tax credits that made marketplace plans affordable for 24 million people expired three weeks ago, on January 1. Premiums for subsidized enrollees just doubled—an average increase of 114%. Congressional estimates project 4 to 5 million people will drop coverage this year alone.

That's on top of the 25 million already disenrolled from Medicaid during the "unwinding" of pandemic-era continuous coverage. On top of the 26 million who were uninsured before any of this started. More will be pushed out by various other means.

The through-line: the system designed around employer-sponsored coverage and means-tested subsidies, now encountering a labor market with fewer stable jobs, a political system incapable of extending temporary fixes, and a regulatory apparatus that alternates between neglect and sabotage. The ACA didn't solve American healthcare. It papered over the structural dysfunction for fifteen years while the underlying conditions worsened.

We're now in the period where that paper comes off.

The market is already there

Before we go further: this is not purely speculative. The market has already found unsettling territory and called it innovation.

I've been writing a recent series here about risk-maxxing—the strategic abandonment of safety mechanisms to gain competitive advantage through deliberately maximalist positions. The key move is externalizing downside while capturing upside. Tesla deploys partial self-driving and users absorb the risk. Crypto markets extract value while building infrastructure designed to make regulated systems obsolete. The gains accrue to first movers; the costs distribute to everyone else.

What follows is risk-maxxing applied to health care. The same logic, the same externalization—but now the asset being leveraged is you.

In the days before U.S. forces extracted Nicolás Maduro from Caracas earlier this month, someone created a Polymarket account and placed $34,000 in bets across several Venezuela-related contracts. When the operation resolved, they walked away with over $400,000. The account had been created days earlier and traded only Venezuela markets. Either this was the luckiest gambler alive, or someone with advance knowledge of a military operation saw an opportunity and took it.

This is what prediction markets look like at scale: people betting on invasions, regime changes, military strikes. Monthly trading volume jumped from $100 million in early 2024 to $13 billion by late 2025. Kalshi has partnered with CNN. Dow Jones with Polymarket. The infrastructure for betting on anything—including human suffering—is maturing rapidly, and the people building it call it information aggregation.

Meanwhile, the administration that signed the executive order opening 401(k)s to crypto and alternative investments also created Trump accounts—government-seeded investment accounts for newborns that must, by law, be invested only in low-cost U.S. stock index funds. The accounts don't even open until July. But the asset management industry is already lobbying Treasury to broaden the investment options. The pattern is familiar: create the infrastructure with guardrails, then remove the guardrails once the infrastructure is normalized. Give it a week or two, and someone will propose letting parents stake their children's trust funds on prediction markets. For the returns.

The point isn't that this is new. People have always found ways to profit from catastrophe. The point is that the tools are becoming more composable, more accessible, and more normalized. What was once the domain of institutional players with exotic derivatives is now available to anyone with a crypto wallet and an internet connection.

A note on method—and hazard

What follows are not predictions or, God help us, suggestions or recipes. They're speculative exercises—the same approach that sits at the center of Money for Mars. Take a financial primitive, cross it with a constraint or population, and trace the logic to see what emerges. Not crazy combinations for shock value, but plausible outcomes that follow from incentives already in motion.

I should be clear about the hazard here. There's a school of thought that imagining dark futures summons them—that speculation provides a blueprint, normalizes the unacceptable, or simply gives bad actors ideas they wouldn't have had otherwise. This concern is not unfounded. We live in an era when the distance between "dystopian thought experiment" and "Series A pitch deck" has collapsed to approximately eight hours—the so-called Torment Nexus problem.

But the alternative—refusing to look—doesn't make the vectors disappear. It just means we encounter them without preparation.

Reality doesn't explain itself enough anymore. The combinations below help clarify what's driving toward these outcomes, which is a prerequisite for doing anything about it. Some anticipatory regulation might help head off the less desirable futures—if the regulators weren't captured, if the legislative process weren't gridlocked, if the people building these systems weren't also funding the campaigns. But understanding the dynamics is still worth something, even when intervention seems unlikely.

So: not advocacy. Not inevitability. Just pattern recognition, applied to a system under stress. It’s dark, but look around you.

The financial toolkit

Three innovations, each solving a different problem.

DeFi emerged to remove intermediaries. Encode rules into self-executing contracts and you don't need banks or brokers. The key property is composability—protocols snap together, enabling combinations their creators never anticipated.

Prediction markets aggregate distributed knowledge. Give people money riding on outcomes and their collective judgment sharpens. Elections, box office, disease outbreaks—skin in the game produces signal. Also, apparently, military operations.

Crowdfunded philanthropy routes resources through narrative. GoFundMe and its descendants bypass institutions entirely, moving money from strangers to need based on story and social proof.

Each works tolerably well in its lane. The interesting part is the intersections.

The healthcare substrate

Health Savings Accounts (HSAs) formalize personal obligation. You're not pooling risk. You're saving against your own decline, alone, with tax advantages as consolation. They were sold as empowerment. They're actually the infrastructure for individual risk-bearing in a system that's forgetting how to share it. And they're likely to be bearing even more risk as the ACA is picked apart and nothing replaces it. It's a Project 2025 feature, not a bug.

The uninsured now number somewhere north of 30 million, depending on how you count and when. That figure will grow significantly this year as subsidy expirations and Medicaid unwinding work through the system. These aren't just people without coverage—they're people outside any collective structure, making every medical decision as an out-of-pocket calculation.

Risk tolerance rises as options narrow. People already skip medications to make rent, ration insulin by the unit, defer surgeries to keep jobs. They're managing their bodies the way a distressed company manages cash flow: deferring maintenance, hoping to make it to the next quarter.

This is the substrate. Now add the toolkit.

The mixes

In Money for Mars, I'd give teams random combinations—Europa + Migrant Worker + Insurance—and watch them figure out what that means when communication blackouts last hours and your day is 3.5 Earth days.

The healthcare version works the same way. Combine a financial primitive with a failure mode and see what emerges. These aren't absurdist combinations. They're logical extensions of incentives that already exist.

1. Outcome staking

HSA + Prediction markets

You already have a financial stake in your own health. Now add a betting layer.

Stake a portion of your health savings on hitting biometric targets by a certain date. A1C under 6. Blood pressure normalized. Ninety days sober. Hit the target, your stake grows. Miss it, the pool redistributes.

The pitch is accountability—money on the line focuses the mind. The reality: people gaming metrics, shopping for favorable testing conditions, a grey market in devices that report generous numbers. "Biometric coaching" services that help you hit your marks by any means necessary.

This isn't far from existing wellness programs with financial incentives. It's just the version where the incentive structure gets teeth.

2. Structured decline timing

Prediction markets + Uninsured

If you could bet against your own health trajectory, you'd have incentive to delay treatment until after a position pays out.

People already skip medications due to cost—this just adds a speculative layer. "I'll get the chest pain checked after the Q2 settlement." The financial logic is clean: if you hold a position that benefits from your own deterioration, every day you defer care is a day closer to payout.

This isn't hypothetical behavior mapped onto a new instrument. It's existing behavior—deferred care, skipped prescriptions, ignored symptoms—given a financial infrastructure. The difference is that now there's an upside to waiting. The downside was always yours.

3. Diagnostic arbitrage

Uninsured + Prediction markets

American medicine is full of ambiguity. Same symptoms, different specialists, different conclusions. Usually this creates expense and confusion.

But ambiguity is volatility, and volatility is tradeable.

Pursue multiple diagnostic pathways while holding positions on each outcome. You're not doctor shopping for prescriptions—you're doctor shopping for optionality. Each specialist's opinion becomes a potential payout.

The condition doesn't change. The uncertainty does the work.

4. Biometric collateral

DeFi + Uninsured

Wearables generate data streams—heart rate variability, glucose curves, sleep architecture. Currently this data mostly sits there, occasionally reviewed by a physician, more often scrolled past by the wearer.

But data is an asset. What if you could pledge yours?

The precedent exists. In 1997, David Bowie securitized the royalties from his first 25 albums—287 songs—and sold them as bonds for $55 million. Prudential bought the lot. It was the first time intellectual property had been packaged this way, and it spawned similar deals for James Brown, the Isley Brothers, and others. Some analysts later argued that Bowie bonds helped normalize the exotic securitizations that eventually blew up in 2008. The conceptual leap: a person's future output—creative, economic, biological—could be an asset class.

Use your biometric stream as collateral against a loan. Healthier readings, better terms. Miss targets, rates adjust. Stop wearing the device, you're in default.

Life insurance already prices on health data. Auto insurance already incorporates driving behavior from phone sensors. The step from "we'll check your credit score" to "we'll check your resting heart rate" is smaller than it appears.

For the uninsured and underbanked, this might be the only collateral available. Your body's current performance, securitized.

5. Condition subscriptions

DeFi + HSA + Crowdfunding

Chronic illness is expensive and unpredictable. But what if you could convert that volatility into a revenue stream?

Tokenize your health trajectory. Investors buy shares in your future medical costs and outcomes. You get capital now—for rent, for food, for the immediate crisis. They get a position in your prognosis.

The healthier you stay, the better their returns. Incentives nominally align. But someone else now has a financial interest in your body's performance. Your medication adherence is their portfolio management. Your flare-ups are their drawdowns. As fictional trading floor VP Will Emerson says in Margin Call, as he dumps toxic mortgage derivatives on institutional customers, “it looks like my loss is your gain.”

Longevity swaps and mortality derivatives exist in institutional finance. This is just the retail version—life settlements for the living.

6. Quadratic funding for rare conditions

HSA + DeFi + Prediction markets

Here's one that almost sounds good.

Patients with orphan diseases pool HSA funds into matching pools. Prediction markets on research milestones determine which trials get funded—hit the Phase II endpoint, the pool releases. You're venture-capitalizing your own potential treatments.

The pitch writes itself: patient-driven research priorities, collective action among the abandoned, democratized drug development. No more waiting for pharma to notice your disease is profitable enough. The community decides what matters.

The problem is the same as every other mix: those with resources to stake have a voice; those without don't. The rarest conditions with the smallest patient pools—the ones most abandoned by the current system—remain abandoned by this one too. And the prediction market layer means someone is always on the other side of your hope. If the trial fails, someone profits. Possibly someone who knew it would.

7. The rescue pump

Crowdfunding + Speculation

GoFundMe campaigns have predictable arcs: launch, plateau, stall, occasionally surge through viral luck or celebrity intervention.

Spot a campaign underperforming relative to need. Take a position on completion. Boost it yourself—strategically, through amplification networks. You're not being charitable. You're market-making for sympathy.

The sophisticated version: launch your own campaign, let it stall, create the despair narrative, take a position on recovery, land a "miraculous" last-minute donor. The donor is you, through intermediaries. You've washed your own hope.

The polarization layer

In Money for Mars, different locations create different constraints. Near-Earth operations can still use traditional banking. Deep space requires autonomous systems that could function for years without Earth verification.

Healthcare polarization works the same way. For the secure, these tools remain curiosities—interesting hedges, philosophical provocations. For the precarious, they become infrastructure.

When you can't afford insurance, you might afford a position against your own decline. When no bank will lend to you, maybe your Oura data will get you in the door. Same instruments, opposite relationship to your own body.

Economic bifurcation doesn't just mean some people have more money. It means the same tools carry different meanings depending on who holds them. The wealthy use prediction markets to diversify. The desperate use them to monetize deterioration.

What the exercise reveals

The point isn't that these specific combinations will emerge exactly as described. Some might. Others will mutate into forms we haven't imagined.

The point is that the components exist, the interfaces are increasingly compatible, and the desperation is real and growing. American healthcare already converts illness into debt. These tools just complete the circuit—making the body legible as a financial instrument, the diagnosis a tradeable signal, the prognosis a betting line. Some MBA somewhere is already looking at health derivatives as a market, probably smiling up at a portraits of the inventors of reverse mortgages and STOLIs.

Understanding these vectors won't stop them. But it might help us see them coming, name what's driving them, and—in some better timeline where governance still functions—build guardrails before the infrastructure locks in.

In space, the constraint is distance. On Earth, the constraint is access. Both reshape what financial instruments mean when you can no longer assume the conditions they were designed for.

*A more extensive version is available if anyone wants to run it. Contact me.