HJBR May/Jun 2025

ceives care, albeit in the most expensive form possible. Hospitals, burdened with providing this uncompensated care, in turn negotiate higher commercial insurance rates with pay- ers, thus passing on the cost of that care to the rest of us in the form of higher insurance premiums. We stop short of being willing to let a person suffer or die because they do not have health insurance, but are blinded to the expensive consequences of having indi- viduals opt out of purchasing health insurance. Two more provisions in the ACA sought to strike a balance between actuarial fair- ness and the solidarity principle. There was a risk-adjustment program where funds from plans with healthier enrollees were trans- ferred to plans with sicker enrollees, thus discouraging insurers from cherry-picking healthy members. Lastly, there were reinsur- ance and risk corridors, which were tempo- rary measures that helped insurers cover the costs of unexpectedly high claims in the early years of the rollout, as previously uninsurable, costly members were added to the risk pool. By limiting the extent of experience rating while still allowing risk-based pricing (age, to- bacco use), the ACA sought to promote fair- ness without making insurance unaffordable for low-risk individuals. While the law suc- cessfully reduced the number of uninsured Americans, it also faced challenges — par- ticularly when younger, healthier individu- als did not enroll at expected levels — lead- ing to rising premiums in some markets. Does that mean the ACA was a failure? Well, it certainly failed in living up to its name, be- cause I doubt that many people would use the word “affordable” if asked to choose one word to describe American healthcare. Conversely, healthcare prior to passage of the ACA was not affordable either. Indeed, by introducing new value-based payment models that incentivize providers and health systems to reduce the to- tal cost of care while improving quality and pro- hibiting rationing, an argument can be made that healthcare would be even more expensive today than it would have been without its pas- sage. And the law did succeed in halving the number of uninsured individuals in this country. In the end, the ACA is neither scapegoat nor savior of healthcare, but when one understands its central tenets as outlined in the last article and this one, only society can decide where we stand on these core principles. Do we value ac- tuarial fairness or social solidarity more? Do we trust the private markets to solve what is wrong with healthcare, or do we favor government intervention? I do not know the right answers here, nor is it my role to decide. Only we as a society can choose which leaders we believe will best express our societal values and how those values will best achieve the right balance of individual freedom and collective good. Delay, Deny, Depose We started the last article by revisiting the tragic murder of a health insurance executive in December 2024. Shockingly, many people celebrated the murder of this man and cheered his alleged murderer, inspired no doubt by per- ceived injustices perpetrated by his company and health insurance in general. UnitedHealth Group is the largest of these private insurers with the highest market share. To better un- derstand some of the angst that is being ex- pressed, let’s use Cigna Health and Life Insur- ance Co. as a representative example. Cigna ranks eighth in market share among private insurers, well below UnitedHealthcare, insur- ing just over 2.5% of the private health insur- ance market. Their CEO earned $23 million last year. Four more of their executives each received an average of between $5.8 and $10.3 million in annual compensation for 2024. Americans do not tend to begrudge people for being successful. Indeed, themes of meri- tocracy generally play quite well across our society as we tend to celebrate those who have achieved success through a combination of smarts, hard work, and business savvy. But, as evidenced by the murder of a health insur- ance executive and the public response to that murder, exorbitant health insurance compensa- tion has crossed a line for many. Why is that? Perhaps the answer can be found inscribed in the shell casings of the bullets fired at Brian Thompson: “delay,” “deny,” and “depose” — not “defend” as was so widely circulated in the media immediately after the incident. The key word there is “deny.” Payers fancy themselves as health promotion companies with plenty of advertisements touting their offerings to help their members live long, healthy, disease-free lives. But many individuals would scoff at the notion of saying that payers are in the busi- ness of health, instead asserting that they are in the business of denial — delay expeditious processing of claims or even deny them be- ing paid altogether. Here is where the soul of health insurance becomes most exposed. Payers are not typically seen as defenders of health, staunchly advocating for their mem- bers, and graciously paying for needed care. In defense of Cigna, in February 2025, they did announce their plans to start linking bo- nus awards for high-level officers to the com- pany’s Net Promoter Score (NPS), a measure of customer loyalty and satisfaction. One has to wonder where they will set the benchmarks though, since their most recent NPS was nega- tive eight (with 39% promoters, 14% passives, and 47% detractors). Their score of negative “Insurance works best if the risk is spread out across a large population, where at least some redistribution from healthy to sick, young to old, etc., is inherent to the business model of insurance.”