When Floridians pay their insurance premiums, whether for auto coverage, business protection, or professional liability, they’re not just buying peace of mind. They’re purchasing a promise that their insurer will step in when something goes wrong and handle their claim fairly and in good faith.

But that promise is unraveling. Thanks to sweeping statutory reforms passed by the Florida Legislature, insurance companies are no longer held to the same standards of accountability. While the changes were sold as a solution to rising premiums and excessive litigation, they’ve gone too far, making it harder, not easier, for everyday Floridians and business owners to get the coverage they’ve paid for. It’s time for lawmakers to fix what they broke.

Bad faith is on the rise — but accountability is on the decline

The recent reforms didn’t eliminate bad faith conduct. They just made it harder to bring legitimate bad-faith cases to light. Insurance companies now have multiple built-in opportunities to “correct” their missteps before a lawsuit can be filed. That might sound reasonable on paper, but in practice, it gives insurers cover to delay, deny, and deflect without facing consequences.

This has shifted the burden onto plaintiffs’ lawyers, particularly in personal injury and wrongful death cases. Today, lawyers must act as stand-in insurance adjusters, completing their own due diligence from the insurer’s perspective and delivering meticulously packaged demands on a silver platter within rigid timelines. Even when they do, insurers often claim they’re still missing key information, buying themselves more time while victims wait.

We recently represented a family in a tragic wrongful death case. We provided clear documentation of liability, outlined damages, and submitted a comprehensive demand. Under the law, the insurance company had 90 days to respond in good faith. But instead of honoring that deadline, they claimed they were still waiting for exposure clarification, despite having all the necessary information. This kind of delay, now legally insulated, shows how reforms have failed the very people they were meant to protect.

Commercial policyholders are being left behind

The misconception that bad faith reform only affects personal injury cases misses a much broader issue: Bad faith conduct is rampant in commercial insurance. We’re seeing it regularly in cases involving Directors and Officers (D&O) liability, general liability, cyber coverage, and Errors and Omissions (E&O) policies.

These are not small claims or unsophisticated policyholders. They’re businesses and professionals who rely on their policies to protect against serious financial exposure. But increasingly, insurance carriers are either denying coverage outright or refusing to tender the full amount owed, even when liability is obvious and the policy should apply. And because of the new reforms, the tools that once helped level the playing field for policyholders are largely unavailable or ineffective.

The pendulum has swung too far. What was intended as tort reform has turned into a liability shield for insurers, undermining the entire premise of good faith coverage.

Premiums keep rising, and insurers keep leaving

If the goal of these legislative changes was to reduce premiums or stabilize the market, it hasn’t worked. Florida consumers and businesses are still seeing premiums climb, and insurance carriers are still pulling out of the state. The only thing that’s changed is that policyholders now have fewer legal remedies when things go wrong.

To make matters worse, lawmakers took a broad approach to addressing property insurance litigation. They swept in unrelated claims, from personal injury to commercial liability to medical billing. Limiting a provider’s ability to sue for unpaid services doesn’t help the property market; it just hurts doctors and patients. This kind of legislative overreach reveals a troubling lack of nuance.

What policyholders need to know

Until the law is corrected, policyholders, particularly business owners and professionals, must be proactive in protecting themselves. That begins with honesty at every stage of the insurance process. From the initial application to the moment a claim is filed, any inconsistency or omission can be used by an insurer as justification for denial. Full disclosure is essential. Providing detailed and complete information up front gives insurers less room to delay or deflect by claiming they lacked sufficient details to evaluate the claim.

Policyholders should also maintain clear, professional communication throughout the process. Every interaction with the insurance company, whether by phone, email, or written correspondence, should be documented and preserved. These records may be critical if a dispute arises down the line. And finally, legal counsel should be engaged early. Waiting until a claim is denied can limit your options; having an attorney involved from the start ensures you’re responding appropriately to requests, complying with policy terms, and preserving your rights. In an environment where the law is no longer on your side, the best defense is preparation, professionalism, and persistence.

Time for a course correction

Florida’s bad faith reform hasn’t lived up to its promise. In fact, it’s failed spectacularly, emboldening insurance companies, harming consumers, and doing little to bring real stability to the market. The law now protects the powerful at the expense of the people it was meant to serve.

This is not a partisan issue. It’s a consumer protection issue. But in a one-party state like Florida, it’s difficult to advance meaningful change when the political and financial interests align so heavily on one side. And in that kind of environment, it’s easy for ordinary Floridians and their businesses to get lost in the shuffle.

Insurance may not be a headline-grabber. But when your claim is denied, your business is at risk, or your family is left without recourse after a tragedy, the stakes couldn’t be higher.

It’s time to restore balance to Florida’s insurance system. The Legislature must revisit the bad faith reforms, restore accountability, and remember why insurance laws exist: to protect the people who pay the premiums.

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Jason Goldman and Aaron Davis are co-founders of Davis Goldman PLLC.

Lawmakers are taking aim at a common problem for Illinois residents who seek mental health care — many therapists don’t take private insurance.

In Illinois and across the country, a number of therapists have stopped accepting private insurance, saying health insurers don’t reimburse them enough money for their services and force them to jump through too many hoops to give patients the care they need. That can leave patients in a bind, forcing them to choose between paying out-of-pocket for care, waiting for care from a therapist who will take their insurance, or sometimes forgoing help altogether.

A bill sponsored by Rep. Lindsey LaPointe, D-Chicago, seeks to address some of the barriers that therapists say keep them from taking private insurance. The bill would require private insurers to pay in-network therapists at least 141% of the rate Medicare pays for the same behavioral health or substance use disorder service.

It also aims to cut red tape for therapists. The bill would prohibit insurers from requiring therapists to submit more documentation to get reimbursed for 60-minute sessions as compared with shorter sessions, and prohibit insurers from denying coverage for multiple behavioral health services or substance use disorder services for the same patient in one day.

It would also require insurers to cover services provided by therapists in training who are being supervised by licensed professionals, and, when a therapist applies to be in-network with an insurer, the insurer would have no more than 60 days to complete the contracting process with the therapist.

The bill would only apply to health insurance plans regulated by the state. Insurance plans offered by many large employers are regulated by the federal government, not the state.

“The ultimate goal is for people to be able to use the insurance they already pay for to access regular behavioral health like therapy and psychiatric appointments,” LaPointe said. They’re not able to do that now because providers won’t join networks because they’re not getting reimbursed enough.”

The bill passed out of the House with a vote of 72-33 and is now in the Senate. The legislative session ends May 31.

The bill, however, faces opposition from insurance industry representatives. The costs of larger reimbursements to therapists could potentially be passed along to consumers, in the form of higher monthly premiums or higher out-of-pocket costs as patients work to meet their deductibles, said Laura Minzer, president of the Illinois Life and Health Insurance Council, which represents health and life insurers.

Minzer also worries about the potential precedent of lawmakers setting reimbursement rates from private insurers for health care.

“It does create sort of a Pandora’s box where we could see other types of providers coming for the same types of considerations in statute,” Minzer said.

She said protections are already in place to make sure therapists are reimbursed fairly, including state and federal parity laws that require insurance companies to cover behavioral health and physical health care equitably. Each year, insurers have to submit to the Illinois Department of Insurance documentation showing that the processes they use to set reimbursement rates for mental health care aren’t any more stringent than those used for other medical care.

It’s also possible that higher reimbursement rates wouldn’t make much of a difference when it comes to persuading more therapists to accept insurance, Minzer said. Some therapists don’t accept insurance because they’re part of small or solo practices that don’t have the bandwidth for the paperwork, she said.

“I’m not sure that increasing rates and requiring reimbursement to be higher is necessarily going to change the dynamic for some sole practitioners who just don’t want to deal with insurance,” Minzer said.

The Council, however, supports many other parts of the bill, outside of the reimbursement provisions, Minzer said.

“It will go a long way to improving the consumer experience as well as addressing some concerns the behavioral health providers have noted,” she said of other parts of the bill.

Blue Cross and Blue Shield of Illinois, which is the largest health insurer in the state, has also said it opposes the bill, though a spokesperson for Blue Cross declined to comment on the issue for this article.

Those behind the bill, however, say the reimbursement provisions are key.

“If you want behavioral health access you have to increase reimbursement rates … and you have to decrease the administrative burdens or the red tape,” LaPointe said.

Some therapists have not seen an increase in insurance reimbursement rates for more than a decade, said Heather O’Donnell, senior vice president of public policy at Thresholds, which serves people with mental health and substance use disorders in Illinois.

Thresholds has been a driving force behind the bill even though most of its patients are on Medicaid, meaning Thresholds might not benefit much from the measure. Increasing access to mental health care in general is important to the organization, O’Donnell said.

“It’s just time private insurance steps to the plate,” O’Donnell said. “In the end, it’s the people seeking care that get the short end of the stick. They’re paying for insurance, but when it comes to needing to see a therapist, it’s incredibly difficult, so oftentimes they have to go out of network and pay out-of-pocket.”

Jennifer Froemel, who owns private practice Innovative Counseling Partners, is concerned about the insurance industry’s opposition to the bill. Though her practice accepts private insurance, she said her reimbursements have changed little in the last 26 years — in at least one case rising by only about $10 per session in that time frame.

“I really feel like right now we are in such a mental health crisis still that we really need to push for equitable pay,” said Froemel, who also serves on an Illinois Counseling Association task force that examines insurance trends in mental health. Higher reimbursement rates would mean more access for patients, she said.

Lawmakers considered a similar bill last year, but that bill failed to pass by the end of the legislature. LaPointe said the bill simply “ran out of time” last year, but this year, “Our colleagues in the House and Senate are much more aware of the bill this year and truly understand it.”

It’s bad enough when home insurance prices rise 10% to 20% per year. But what if they went up 10 to 20 times?

We are two longtime California residents who have worked more than 30 years in and around business and finance. We’ve spent the last year asking two basic questions: What’s wrong with homeowners insurance in California? And is there actually an opportunity to launch a new insurer while so many other carriers flee the market?

The math is not pretty. We’d tell you to cover your eyes, but then you wouldn’t be able to read just how bad it is:

We estimate that 20% to 30% of homes in California have high exposure to wildfire risk, compared to the state’s outdated estimate of 12%. To price those risks, let’s use a simple example. If your home costs $1 million to replace and the expected likelihood of a wildfire loss has gone from a 1-in-400-years event to a 1-in-50-years event, then the premium required just to cover catastrophic wildfire risk increases from $2,500 per year to $20,000 per year. And that excludes all the other risks like theft and water damage.

In a state where the average home price is nearly $900,000 and an average premium hovers around $2,000, this increase is both economically infeasible and politically disastrous.

Over the last two years, eight of the largest 12 California carriershave aggressively reduced their new customers or even exiled existing customers.

No private company will, or should be expected to, offer insurance that is unprofitable.

So, what’s changed from the past, when the homeowners insurance market was more stable? Well, there are simply more dangerous wildfires. The frequency and intensity of these fires has broken existing underwriting models, and insurers are terrified. According to CalFire, more structures in California were destroyed by fire in each of 2017, 2018, and 2020 than in all 10 years prior to 2017 combined. The years 2017 and 2018 were brutal, with wildfire losses consuming approximately twice total premiums collected. It’s hard to say where the figures for 2025 will end, but it will of course be terrible, too.

And despite good intentions, decades of political grandstanding and a short-sighted Californian regulatory approach are also responsible for this mess.

In 1988, voters passed Proposition 103 in an attempt to tame insurance-rate increases. It may have worked for a time. But the deal came with other features that slowly rotted the entire system. There was an elected insurance commissioner, an extremely slow approval process for rate increases, and rigid rules on how insurers set prices.

That was just the start. California also created an Intervenor process—unique to this state—that allows third parties to object to rate increases (and pays them for doing so). Insurers simply could not keep pace with their own costs. So, they gave up.

Another unpleasant surprise lurks in the shadows for insurers—assessments from the Fair Access to Insurance Requirement (FAIR) plan, the state’s insurer of last resort.

When the FAIR plan’s capital is unable to cover losses (as is almost certain to be the case in 2025), the FAIR plan will make an assessment on regulated insurance carriers in California in line with their market share.

For example, the FAIR plan is likely to incur $4 billion of gross losses from the January fires. California regulators have already approved a $1 billion assessment against insurers to keep the FAIR plan solvent. Therefore, State Farm—which has approximately 20% share in California—already has a $200 million bill—for policies that it didn’t underwrite and aren’t on its books. And more assessments could be coming if loss estimates get worse.

In essence, to operate as a regulated carrier in California, a private insurer is exposing itself to unknown and uncapped losses for risks it never knowingly assumed. This is, literally, like being sent a bill for your neighbor’s house when it burns down and yours is still standing.

At this point, State Farm could, in theory, ask to pass most of this on to existing customers—but you can imagine the reaction of policyholders and politicians to that idea. Now do you see why insurers are leaving the state?

With this context, we see only three paths available to the state and its citizens. Only one has a shot of really working.

Let insurers price insurance to reflect their true cost. The good news is that insurers will show up if they can price freely, but the bad news is that high-risk properties will get massive premium increases commensurate with risk. This will likely bring a substantial fall in home values and property taxes—because the pool of buyers who can afford the true cost of insurance will be small. Many homes would likely end up uninsured. A small plus is that it would align behavior with risk mitigation—building that new house deep in the wilderness may no longer seem like such a good idea. Force insurers to insure high-risk homes, and in effect have the premiums of low-risk homes subsidize those in higher-risk areas. A sloppy version of this approach is what seems to be in place today—either through new rules attempting to coerce (or entice?) insurers to write in high-risk areas or through the FAIR plan backstop for which insurers are liable for assessments. But for this to work, pricing in aggregate still needs to be adequate, and the insurers—especially after the LA fires—are unlikely to think that it will be. There’s also another risk: Inherent in this approach are significant cross-subsidies, where high-risk homeowners are charged less than they should be—in order to make the price reasonable—while low-risk homeowners are overcharged in order for the overall portfolio’s pricing to be adequate. So there’s an incentive for low-risk homeowners to opt out of coverage or seek other specialized products—and then the system unravels. The state addresses the higher-wildfire-risk homes in some manner and lets the private market deal with the lower-wildfire-risk homes. This would allow 80% of the market to go back to functioning. We think the state would likely need to backstop high-risk homes—probably with some kind of subsidy or tax credit that phases out over time—to avoid an insurance payment or a real estate price shock today. Over time, however, people will pay the actual cost of risk and incentives will correctly align around risk mitigation and building location choices. And the simple act of drawing lines—between high-risk and low-risk—will be a politically explosive issue.

After 12 months wading through the arcana and folly of California insurance, we see no alternative but number three. And because insurance carriers are, appropriately, long-term analysts of risk, they will continue to reduce exposure to California unless real policy change is enacted. And so the hard truth remains: Not only will the future bring more wildfires, it will also bring declining home prices and greater financial risk and stress for all Californians.

The opinions expressed in Fortune.com commentary pieces are solely the views of their authors and do not necessarily reflect the opinions and beliefs of Fortune.

Agents help sign people up for insurance through Covered California. Californians are struggling to keep up with rising health insurance premiums.

California businesses saw employees’ monthly family insurance premiums rise nearly $1,000 over a 15-year period, more than double the pace of inflation.

Kirk Vartan pays more than $2,000 a month for a high-deductible health insurance plan from Blue Shield on Covered California, the state’s Affordable Care Act marketplace. He could have selected a cheaper plan from a different provider, but he wanted one that includes his wife’s doctor.

“It’s for the two of us, and we’re not sick,” said Vartan, general manager at A Slice of New York pizza shops in the Bay Area cities of San Jose and Sunnyvale. “It’s ridiculous.”

Vartan, who is in his late 50s, is one of millions of Californians struggling to keep up with health insurance premiums ballooning faster than inflation.

Average monthly premiums for families with employer-provided health coverage in California’s private sector nearly doubled over the last 15 years, from just over $1,000 in 2008 to almost $2,000 in 2023, a KFF Health News analysis of federal data shows. That’s more than twice the rate of inflation. Also, employees have had to absorb a growing share of the cost.

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The spike is not confined to California. Average premiums for families with employer-provided health coverage grew as fast nationwide as they did in California from 2008 through 2023, federal data shows.

Premiums continued to grow rapidly in 2024, according to KFF.

Small-business groups warn that, for workers whose employers don’t provide coverage, the problem could get worse if Congress does not extend enhanced federal subsidies that make health insurance more affordable on individual markets such as Covered California, the public marketplace that insures more than 1.9 million Californians.

Premiums on Covered California have grown about 25% since 2022, roughly double the pace of inflation. But the exchange helps mitigate high costs nearly 90% of enrollees by offering state and federal subsidies based on income, with many families paying little or nothing.

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Rising premiums also have hit government workers — and taxpayers. Premiums at CalPERS, which provides insurance to more than 1.5 million of California’s active and retired public employees and family members, have risen about 31% since 2022. Public employers pay part of the cost of premiums as negotiated with labor unions; workers pay the rest.

“Insurance premiums have been going up faster than wages over the last 20 years,” said Miranda Dietz, a researcher at the UC Berkeley Labor Center who focuses on health insurance. “Especially in the last couple of years, those premium increases have been pretty dramatic.”

Dietz said rising hospital prices are largely to blame. Consumer costs for hospitals and nursing homes rose about 88% from 2009 through 2024, roughly double the overall inflation rate, according to data from the Department of Labor. The rising cost of administering America’s massive healthcare system has also pushed premiums higher, she said.

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Insurance companies remain highly profitable, but their gross margins — the amount by which premium income exceeds claims costs — were fairly steady during the last few years, KFF research shows. Under federal rules, insurers must spend a minimum percentage of premiums on medical care.

Rising insurance costs are cutting deeper into family incomes and squeezing small businesses.

The average annual cost of family health insurance offered by private sector companies was about $24,000, or roughly $2,000 a month, in California during 2023, according to the U.S. Department of Health and Human Services. Employers paid, on average, about two-thirds of the bill, with workers paying the remaining third, about $650 a month. Workers’ share of premiums has grown faster in California than in the rest of the nation.

Many small-business workers whose employers don’t offer healthcare turn to Covered California.

During the last three decades, the percentage of businesses nationwide with 10 to 24 workers offering health insurance fell from 65% to 52%, according to the Employee Benefit Research Institute. Coverage fell from 34% to 23% among businesses with fewer than 10 employees.

“When an employee of a small business isn’t able to access health insurance with their employer, they’re more likely to leave that employer,” said Bianca Blomquist, California director for Small Business Majority, an advocacy group representing more than 85,000 small businesses across America.

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Vartan said his pizza shop employs about 25 people and operates as a worker cooperative — a business owned by its workers. The small business lacks negotiating power to demand discounts from insurance companies to cover its workers. The best the shop could do, he said, were expensive plans that would make it hard for the cooperative to operate. And those plans would not offer as much coverage as workers could find for themselves through Covered California.

“It was a lose-lose all the way around,” he said.

Mark Seelig, a spokesperson for Blue Shield of California, said rising costs for hospital stays, doctor visits, and prescription drugs put upward pressure on premiums. Blue Shield has created a new initiative that he said is designed to lower drug prices and pass on savings to consumers.

Even at California companies offering insurance, the percentage of employees enrolled in plans with a deductible has roughly doubled in 20 years, rising to 77%, federal data show. Deductibles are the amount a worker must pay for most types of care before their insurance company starts paying part of the bill. The average annual deductible for an employer-provided family health insurance plan was about $3,200 in 2023.

During the last two decades, the cost of health insurance premiums and deductibles in California rose from about 4% of median household income to about 12%, according to the UC Berkeley Labor Center, which conducts research on labor and employment issues.

As a result, the center found, many Californians are choosing to delay or forgo healthcare, including some preventive care.

California is trying to lower healthcare costs by setting statewide spending growth caps, which state officials hope will curb premium increases. The state recently established the Office of Health Care Affordability, which set a five-year target for annual spending growth at 3.5%, dropping to 3% by 2029.

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Failure to hit targets could result in hefty fines for healthcare organizations, though that probably wouldn’t happen until 2030 or later.

Other states that imposed similar caps saw healthcare costs rise more slowly than states that did not, Dietz said.

“Does that mean that healthcare becomes affordable for people?” she asked. “No. It means it doesn’t get worse as quickly.”

The U.S. has made great progress in getting more people insured since the Affordable Care Act took effect in 2014. The share of uninsured Americans ages 18 to 64 fell from 18% before the ACA to 9.5% in 2022. And preexisting conditions no longer prevent coverage or lead to an increase in premiums.

Yet even for those with health insurance, coverage does not ensure access to care, much less high-quality and affordable care. Research shows that 1 in 3 Americans seeking care report delaying or forgoing treatment because of the “administrative burdens” of dealing with health insurance and the health care system, creating additional barriers beyond costs.

Some of these are basic tasks, such as scheduling appointments. But others relate to strategies that health insurers use to shape the care that their patients are able to receive – tactics that are often unpopular with both doctors and patients.

In addition, more than 40% of Americans under 65 have high-deductible plans, meaning patients face significant upfront costs to using care. As a result, nearly a quarter are unable to afford care despite being insured.

As scholars of health care quality and policy, we study how the affordability and design of health insurance affects people’s health as well as their out-of-pocket costs.

We’d like to unpack five of the most common strategies used by health insurers to ensure that care is medically necessary, cost-effective or both.

At best, these practices help ensure appropriate care is delivered at the lowest possible cost. At worst, these practices are overly burdensome and can be counterproductive, depriving insured patients of the care they need.

Claim denials

The strategy of denial of claims has gotten a lot of attention in the aftermath of the killing of UnitedHealthcare chief executive officer Brian Thompson, partly because the insurer has higher rates of denials than its peers. Overall, nearly 20% of Americans with coverage through health insurance marketplaces created by the ACA had a claim denied in 2021.

While denial may be warranted in some cases, such as if a particular service isn’t covered by that plan – amounting to 14% of in-network claim denials – more than three-quarters of denials in 2021 did not list a specific reason. This happens after the service has already taken place, meaning that patients are sent a bill for the full amount when claims are denied.

Although the ACA required standardized processes for appealing claims, patients don’t often understand or feel comfortable navigating an appeal. Even if you understand the process, navigating all of the paperwork and logistics of an appeal is time-consuming. Gaps by income and race in pursuing and winning appeals only deepen mistrust among those already struggling to get appropriate care and make ends meet.

Prior authorization

Prior authorization requires providers to get approval in advance from the insurer before delivering a procedure or medication – under the guise of “medical necessity” as well as improving efficiency and quality of care.

Although being judicious with high-cost procedures and drugs make intuitive sense, in practice these policies can lead to delays in care or even death.

In addition, the growing use of artificial intelligence in recent years to streamline prior authorization has come under scrutiny. This includes a 2023 class action lawsuit filed against UnitedHealthcare for algorithmic denials of rehabilitative care, which prompted the federal government to issue new guidelines.

The American Medical Association found that 95% of physicians report that dealing with prior authorization “somewhat” or “significantly” increases physician burnout, and over 90% believe that the requirement negatively affects patients. The physicians surveyed by the association also reported that over 75% of patients “often” or “sometimes” failed to follow through on recommended care due to challenges with prior authorizations.

Doctors and their staff may deal with dozens of prior authorization requests per week on average, which take time and attention away from patient care. For example, there were nearly two prior-authorization requests per Medicare Advantage enrollee in 2022, or more than 46 million in total.

Smaller networks

Health insurance plans contract with physicians and hospitals to form their networks, with the ACA requiring them to “ensure a sufficient choice of providers.”

If a plan has too small of a network, patients can have a hard time finding a doctor who takes their insurance, or they may have to wait longer for an appointment.

Despite state oversight and regulation, the breadth of plan networks has significantly narrowed over time. Nearly 15% of HealthCare.gov plans had no in-network physicians for at least one of nine major specialties, and over 15% of physicians listed in Medicaid managed-care provider directories saw no Medicaid patients. Inaccurate provider directories amplify the problem, since patients may choose a plan based on bad information and then have trouble finding care.

Surprise billing

The No Surprises Act went into effect in 2022 to protect consumers against unexpected bills from care received out of network. These bills usually come with a higher deductible and an out-of-pocket maximum that is typically twice as high as in-network care as well as higher coinsurance rates.

Prior to that law, 18% of emergency visits and 16% of in-network hospital stays led to at least one surprise bill.

While the No Surprises Act has helped address some problems, a notable gap is that it does not apply to ambulance services. Nearly 30% of emergency transports and 26% of nonemergency transports may have resulted in a surprise bill between 2014 and 2017.

Pharmacy benefit managers

The largest health insurance companies all have their own pharmacy benefit managers.

Three of them – Aetna’s CVS Caremark, Cigna’s Express Scripts and UnitedHealthcare’s Optum Rx – processed almost 80% of the total prescriptions dispensed by U.S. pharmacies in 2023.

Beyond how market concentration affects competition and prices, insurers’ owning pharmacy benefit managers exploits a loophole in how much insurers are required to spend on patient care.

The ACA requires insurers to maintain a medical loss ratio of 80% to 85%, meaning they should spend 80 to 85 cents of every dollar of premiums for medical care. Pharmaceuticals account for a growing share of health care spending, and plans are able to keep that money within the parent company through the pharmacy benefit managers that they own.

Moreover, pharmacy benefit managers inflate drug costs to overpay their own vertically integrated pharmacies, which in turn means higher out-of-pocket costs based on the inflated prices. Most pharmacy benefit managers also prevent drug manufacturer co-pay assistance programs from counting toward patients’ cost sharing, such as deductibles, which prolongs how long patients have to pay out of pocket.

Policy goals versus reality

Despite how far the U.S. has come in making sure most Americans have access to affordable health insurance, being insured increasingly isn’t enough to guarantee access to the care and medications that they need.

The industry reports that profit margins are only 3% to 6%, yet the billions of dollars in profits they earn every year may feel to many like a direct result of the day-to-day struggles that patients face getting the care they need.

These insurer tactics can adversely affect patients’ health and their trust in the health care system, which leaves patients in unthinkably difficult circumstances. It also undercuts the government’s goal of bringing affordable health care to all.