What triggered your conversion from an outspoken advocate for, to an outspoken critic of, the big insurers?

I was becoming increasingly concerned about the strategic direction health insurers were heading, but there also were two events in particular that contributed to my decision to leave my job at Cigna and become a critic of the industry. Cigna and other big insurers realized in the early 2000s that managed care was not working to bring down the cost of health care. So they turned to what was referred to back then as consumer-directed health plans (CDHPs).

The main element of a CDHP plan was and is high out-of-pocket requirements. I knew from my own research that high-deductible plans would not be good for middle-income families and people with chronic conditions. I was right to be concerned. Today millions of Americans with insurance can't use their coverage because in many cases they must spend thousands of dollars out of their own pockets before their coverage will kick in. As a result, many are not going to the doctor when they should and are walking away from the pharmacy counter because they can't afford their medications.

Also, around this time, I went to visit family in Tennessee. While I was there, I went out of curiosity to a big popup clinic being held at a nearby fairground. What I saw that day shocked me: people lined up by the hundreds waiting to get care in animal stalls. I knew I could have been one of them if I hadn't had a few lucky breaks in my life.

A few months later, another event occurred that was the straw that broke the camel's back. Cigna refused to pay for a liver transplant for a 17-year-old girl in Los Angeles. It became such a PR problem for the company that the CEO finally agreed to cover it. Unfortunately, by the time he had decided to do that, she had gotten sicker and died that same day. I did not have it in me to handle any more cases like that. I turned in my notice not long after that.

Explain the dire implications of the term "disintermediation" to major insurance companies. Is this something they truly should fear?

Yes—and it is why you are seeing big insurers diversifying so much and so rapidly. They know they can't keep raising premiums and deductibles forever. Employers are getting fed up with the status quo and are seeking alternatives. The really big companies are going so far as to sideline insurers and contract directly with hospital systems where they have operations and a lot of employees.

What is their strategic response to the threat of being an eliminated middleman in the employer benefits plan equation?

Insurers are getting more and more into the delivery of health care. Cigna, Aetna and United already have large and growing PBM operations, and all the big insurers are buying physician practices and clinics. United already is the largest employer of doctors in the US.

Tell us about the significance of the partnership forged between the Purchaser Business Group on Health (PBGH) and the Colorado Business Group on Health (CBGH)?

It is significant in that these two large groups, which represent the interests of employers of varying sizes, are working to make direct contracting an affordable alternative for their members. PBGH, the bigger of the two, represents the interests of companies that insurers care most about: "jumbo" employers with thousands of employees. A large percentage of insurers' revenues come from those large employers.

What role has Health Rosetta played in altering the employer benefits plan playing field?

A significant role. Health Rosetta works with local and regional employers, including municipalities, to find more affordable options for their workers. And not just affordable but high-quality care. Health Rosetta is helping those employers reduce costs while also improving the health of their employees.

If the major insurers' long-term plan is to become health care providers themselves, do you think they will be able to provide competitive products and services for employer plan sponsors and their plan members?

They will certainly try to do that, and they will do it largely by acquiring the capacity and talent rather than building it in-house. So it will be important for hospital systems, physician practices and other providers to understand the changing landscape.

What are the challenges standing in the way of better employer benefits plans at a lower cost? Will Congress act to reduce the power of the insurance companies?

I do think the Biden administration will put more scrutiny on insurers' M&A plans and even look at the consequences of some that already have been approved. I also think Congress and the FTC will begin to pay more attention. Insurers will spend heavily on lobbying to keep that from happening, but I believe we will see heightened scrutiny by policymakers in Washington and state capitols. It is long past due.

Is the broker community awake to offering more progressive benefits plans?

The broker community absolutely must be awake to the changing environment and be more responsive to the needs and demands of their employer customers. The profession will have to change. Many are dissatisfied with the way the system works and how tethered they are to insurance companies. I think there will be more of them over time.

Are enough employers willing to risk scrapping traditional plans in favor of innovative ones?

I do think many employers already are receptive to scrapping the plans they currently offer. They know there is a limit not only to premium increases but also to how much you can burden employees with out-of-pockets. A recent survey of CEOs by PBGH and Kaiser Family Foundation bore that out. Almost 9 in 10 said the current system will be unsustainable for them within the coming 5 to 10 years. Not only are they sick and tired of devoting more and more of their revenues to health insurance premiums, but they also hate having to saddle their employees with insurers' out-of-pocket requirements, which are now far beyond what many workers can afford.

Read more: 

• Slipping away: Does the employer-sponsored health care system have an expiration date?
• Lessons from COVID: Health care transformation starts when employers demand value
• Who shoulders the greatest burden of out-of-pocket health care costs?