One of the common criticisms leveled at private health insurance companies is that they are profiting at the expense of sick people. But let's take a closer look at the data and see where it takes us. Do private health insurance companies really make unreasonable profits?

How Common Is Private Health Insurance?

Before addressing the question about profits, it's important to look at how common having private health insurance really is in the United States. In other words, how many people might be affected by this question.

According to Kaiser Family Foundation data, roughly a third of Americans had public health insurance in 2018 (mostly Medicare and Medicaid).﻿﻿ Another 9% were uninsured, but the rest had private health insurance that they either purchased on their own in the individual market (6%) or coverage provided by an employer (49%). So nearly half of Americans have coverage provided by an employer, although 61% of them have coverage that's partially or fully self-funded by the employer (that means the employer uses its own money for covering employees' medical costs, rather than purchasing coverage from a health insurance carrier; in most cases, the employer contracts with a commercial insurance company to administer the benefits—so the enrollees might have plan ID cards that say Humana or Anthem, for example—but it's the employer's money that's being used to pay the claims, as opposed to the insurance company's money).﻿﻿

But many Medicare and Medicaid beneficiaries also have coverage that's provided via a private health insurance company, despite the fact that they are enrolled in publicly-funded health care plans. As of 2020, about 40% of Medicare beneficiaries are enrolled in Medicare Advantage plans (and a handful of Medicare Cost plans) run by private health insurance carriers.﻿﻿ Enrollment in private Medicare Advantage plans has been steadily growing since the early 2000s, at a rate that far outpaces the overall growth in total Medicare enrollment.﻿﻿

Even among Original Medicare beneficiaries, millions are enrolled in Medigap plans and/or Medicare Part D plans, both of which are provided by private insurance companies.

And 39 states have Medicaid managed care contracts with private insurance companies to cover some or all of their Medicaid enrollees.﻿﻿

When we put all that together, it's clear that a significant number of Americans have health coverage that's provided or managed by a private health insurance company. And private health insurance companies tend to get a bad rap when it comes to healthcare costs.

Are Insurer Profits Unreasonable?

When we talk about health insurer profits, it's common to see people conflating revenue with profits which adds to the confusion about this subject. Of course, major health insurance carriers have significant revenue, given that they're collecting premiums from so many insureds.

But regardless of how much revenue carriers collect in premiums, they're required to spend most of it on medical claims and health care quality improvements. And although a common criticism is that health insurance companies pay their CEOs too much, that's more reflective of the fact that CEO salary growth—across almost all industries—has far outpaced overall wage growth over the past several decades.﻿﻿ There are no health insurance carriers represented among the 40 firms with the highest-paid CEOs, although there are several pharmaceutical and biotechnology companies.﻿﻿

So while a seven or eight-figure CEO salary seems absurd to the average worker, it's certainly in line with the corporate norm. And health insurance company CEOs are not among the highest-paid CEOs of large companies. The fact remains that salaries are part of the administrative costs that health insurance companies are required to limit under the Affordable Care Act's medical loss ratio (MLR) rules. And so are profits.

Under the MLR rules, insurers that sell individual and small group health insurance coverage must spend at least 80% of premiums on medical claims and quality improvements for members. No more than 20% of premium revenue can be spent on total administrative costs, including profits and salaries. And for insurers that sell large group coverage, the minimum MLR threshold is 85%. Insurers that fail to meet these guidelines (ie, they spend more than the allowed percentage on administrative costs, for whatever reason) are required to send rebates to the individuals and employers groups who had coverage under those policies. From 2012 to 2019, under the MLR rule implementation, insurers rebated $5.3 billion to consumers.﻿﻿

The ACA's medical loss ratio rules also apply to Medicare Advantage plans and Medicare Part D plans, which are required to spend 85% of revenue on medical claims and quality improvements (ie, the same as large group health insurance plans). Insurers that consistently fail to meet this requirement are barred from enrolling new members.﻿﻿

How Much Do Health Insurers Profit?

If we look at average profit margins by industry, health insurance companies are in the single digits.﻿﻿ Health insurers struggled with a lack of profits in the early years of ACA implementation, but had become profitable again by 2018 and have continued to generate profits since then.﻿﻿

For perspective, however, banking, private equity, and commercial leasing industries have profit margins ten times as high as the health insurance industry.﻿﻿ As far as health care goes, there are certainly some very profitable sectors, including medical and diagnostic laboratories, biotechnology companies—and the pharmaceutical industry, which generates the majority of the profits in the health care sector.﻿﻿

But health insurance doesn't have the sort of profitability those industry segments are able to generate—partly because health insurance is much more regulated. As described above, the ACA effectively limits the profits insurers can generate, by capping total administrative costs (including profit) as a percentage of revenue. But there's no similar requirement for hospitals, device manufacturers, or drug manufacturers.

Bottom Line on Profits for Private Insurance Companies: Reasonable or Unreasonable?

Health care costs are the driving factor behind health insurance premiums. It's true that private health insurance companies pay their CEOs competitive salaries and they must remain profitable in order to stay in business. But their profits are modest when compared with many other industries, even within the health care sector.

There is certainly a valid argument in favor of removing the profit motive from health care altogether, which is fueling the surge in support for single payer in the U.S. Proponents of a single-payer system generally contend that health care is inherently different from other industries, and should not be profit-driven. On the other hand, supporters of a profit-based health care system believe that profit is essential for encouraging innovation and quality improvements.

Currently, health insurers are the only segment of the health care industry in which profits are directly curtailed, via the ACA's MLR rules. In the rest of the industry (ie, hospitals, device manufacturers, pharmaceuticals, etc.), a more free-market approach is taken. There is certainly an argument to be made for eliminating or further curtailing the profits generated in the health insurance industry, but there is a similar argument for reducing or eliminating profits in health care in general.

If you have further questions after reading about profits, learn about the best resources for finding information about health insurance and health policy.