I’d like to introduce you to a couple of former colleagues of mine who played key roles in making sure you pay a lot out of your own pocket before your coverage kicks in.

Meet David Cordani, CEO of Cigna, and Karen Lynch, CEO of CVS Health, which now owns Aetna. Like me, Karen is a Cigna alum.

I worked with David and Karen when all three of us were climbing the corporate ladder at Cigna in the late ‘90s and early 2000s. 

David and Karen have to know that millions of people enrolled in Cigna and Aetna health plans, including many of their own employees, are skipping doctor visits and walking away from the pharmacy counter without their prescriptions because they simply don’t have enough money in the bank to cover their health plans’ out-of-pocket requirements. I remember vividly when every Cigna employee, regardless of income, was forced into a high-deductible plan as part of the company’s “full-replacement” strategy, a strategy Cigna and other big insurers encouraged their employer customers to adopt. Many did, eliminating all other health insurance options for their workers. 


I’m calling on David and Karen to work with me once again, along with the LOOP Now Coalition, a diverse group of organizations and companies I’m now leading, to find solutions to what has become a rapidly growing crisis of underinsurance – a crisis all three of us had a hand in creating.

Like me, David and Karen had to know the day would come when an untold number of insured Americans–including many on their payroll–would be dying prematurely or sinking deep into debt–or both–because we and other industry executives insisted they start putting more financial “skin in the game.” 

That “skin” took the form not only of deductibles but also copayments and coinsurance obligations. The Commonwealth Fund has estimated that more than 40% of people enrolled in “Obamacare” marketplace plans and nearly a third of people enrolled in employer-sponsored health plans are now underinsured, primarily because of unaffordable out-of-pocket requirements. As a consequence, tens of thousands of American families with insurance are filing for bankruptcy every year because of medical debt. Many others, including many people enrolled in Aetna and Cigna health plans, are begging for money on GoFundMe.

David and Karen are now corporate rock stars. In 2020–during the height of the pandemic–Cigna paid David nearly $79 million. By contrast, the median employee’s annual compensation at Cigna is just north of $62,000, according to a 2015 payscale.com analysis, the most recent available.

Aetna recruited Karen as an executive vice president in 2012, and her star continued to rise there. She was serving as president of Aetna when CVS bought the company in 2017. In 2020 her total compensation was $11.3 million, far less than David made that year but still far more than most American business executives, and far more than the average CVS employee. Payscale.com found that in 2015, Karen’s predecessor, Larry Merlo, made 434 times the median CVS employee pay of $27,900. That was the largest ratio between CEO and employee pay at any big U.S. company. Like David, most of Karen’s compensation is in stock awards and grants tied to various performance metrics.

The Aetna acquisition catapulted CVS to #4 on the Fortune 500 list of U.S. companies. In February of last year, Karen was tapped to lead the entire company, not just the health insurance business under the Aetna brand, making her the highest ranking female executive in America. 

Both David and Karen played leading roles in an industry-wide strategy that began in the early 2000s to move as many Americans as possible, as quickly as possible, into what we in the industry called, euphemistically, “consumer-directed health plans” (CDHPs for short).  Even the strategy itself had a euphemistic name: consumerism. We in the industry argued that we Americans would become more prudent health care “consumers” when we had to pay more out of our own pockets for care we needed, that we would “shop” for the most cost-effective health care providers.

The roll-out was a massive con job, and I was expected to be a leading player in it. My job as VP of corporate communications at Cigna was to sell the story that both health care costs and insurance premiums were skyrocketing because Americans were too insulated from the real (and ever-increasing) cost of their medications, their doctor visits and a stay in the hospital. It was a ruse. People cannot “shop” for care when they’re having a heart attack or have been hit by a bus. Even when we try to find high-quality care at a reasonable price, we find the information we need is next to impossible to get our hands on. 

The real reason for the “consumerism” strategy (aside from the fact that insurers–including big ones like Aetna and Cigna–have little ability and even little interest in controlling the prices of health care goods and services) was to relieve insurers of the obligation of paying billions of dollars in medical claims every year.

Both David and Karen undoubtedly were in the same company leadership meeting I was in when Cigna kicked off its consumerism strategy in 2005. As I wrote in Deadly Spin, Ken Sperling, the industry consultant Cigna had recruited from Hewitt Associates (now Aon Hewitt), one of the big benefits consulting firms, to lead the company’s strategy, painted a rosy picture of health care consumerism. But many of us were skeptical and peppered Ken with questions. We could understand how Cigna and our corporate customers could benefit from moving employees into high-deductible plans, but we were not convinced it would be good for average people. Ken eventually grew exasperated and said, “Look, you’re just going to have to drink the Kool Aid.”

Even I drank it for a while, believing my own PR. But I eventually learned through a growing number of studies and reports that CDHPs were leading to the financial ruin of countless American families. I’m sure you’ve seen the same studies and know that because of the “consumerism” strategy, most of the people now filing for bankruptcy due to medical debt, have health insurance. New data released just last week by the Kaiser Family Foundation shows that 16 million people, or 6% of U.S. adults, owe more than $1,000 in medical bills, and 3 million people owe more than $10,000. The financial burden falls disproportionately on people with disabilities, those in generally poor health, Black Americans and people living in the South or in non-Medicaid expansion states.

Many of them have put so many medical expenses on their credit cards – expenses that were once covered routinely by insurers – they can’t possibly pay off their debt. 

David and Karen, here are just a few facts you need to know, all based on recent research:

  • High-deductible plans incentivize patients, particularly those with low incomes, to avoid care because doing so subjects them to financial burdens insurance was supposed to prevent.
  • Premium contributions and deductibles in employer plans accounted for 11.5% of median household income in 2019, up from 9.1% a decade earlier.
  • Even a seemingly modest increase in out-of-pocket costs causes many patients to stop taking drugs they need. For example, raising Medicare recipients’ out-of-pocket costs by just $10 per prescription led to a 23% drop in overall drug consumption and a 33% increase in mortality.
  • Patients of color face greater barriers to care than others because of high-deductible health plan costs. Black cancer survivors with a high-deductible plan were more likely to skip medications to save money than white cancer survivors with the same plans (22.8% versus 8%, respectively).
  • Deductibles have gotten so high that nearly one-third of people with above-the-median total annual health care spending (plan plus out-of-pocket spending) incurred half of their annual out-of-pocket spending in just one day.

David and Karen, no one enrolled in your health plans–or any health plan, for that matter–should have to decide between picking up their prescriptions and putting food on the table. I’m confident you would agree that the evidence is overwhelming that the industry’s consumerism strategy has created a nightmare for millions of Americans who, because of unaffordable out-of-pockets, are now functionally uninsured. It is long past time for you and other industry leaders to come up with a new and fairer strategy. Can we join forces again, this time to get us out of the crisis we all had a hand in creating?