After public outrage and political pressure, insurers like Cigna are rolling out “reforms” and glossy reports but the same opaque systems of denial, delay and self-policing remain.
On the morning of December 4, 2024, Brian Thompson, the CEO of UnitedHealthcare, was shot and killed outside a Manhattan hotel. What happened next stunned the health insurance industry — and, I suspect, haunts its communications teams to this day.
The public reaction wasn’t what anyone expected. Yes, there was shock and grief. But alongside it (in some corners overwhelming it) came something the industry had never quite experienced at that scale: a torrent of personal testimony. On social media, millions of people shared their own stories. Denied claims. Delayed treatments. Coverage that evaporated precisely when it was needed most. Loved ones who died waiting for approvals that never came. The posts spread faster than any industry crisis communications team could track. What should have been a moment of straightforward public sympathy became, almost immediately, a referendum on the entire business model of private health insurance in America.
Within weeks, Cigna, where I used to work, announced what it called a “multi-year effort” to transform the health care experience for its customers — framed around five aspirational priorities: easier access to care, better support, better value, accountability, and transparency. In March, the company published its first Customer Transparency Report. Last week, just days before Cigna’s first-quarter earnings call this Thursday, it joined UnitedHealthcare, Aetna, Elevance, Humana, and dozens of other insurers in an industry-wide pledge, coordinated by the trade association AHIP, to standardize electronic prior authorization submissions.
The pledges sound real. The question is whether they represent genuine reform or a carefully constructed substitute for it — one designed to satisfy a restless public, reassure a new administration and protect the industry from the legislation and regulation that would actually change how it operates.
You won’t be surprised that I view the pledge as a carefully constructed substitute for real reform.
The deal with the administration
The current pledge didn’t emerge organically from a suddenly conscience-stricken industry. It clearly was negotiated.
On June 23, 2025, HHS Secretary Robert F. Kennedy Jr. and CMS Administrator Dr. Mehmet Oz hosted a roundtable with insurance industry leaders — Cigna, UnitedHealthcare, Aetna, Elevance, Humana, Centene, and others — where the companies pledged six key reforms to streamline prior authorization. The administration praised the voluntary commitments. Federal health officials told reporters they were prepared to issue new regulations if insurers didn’t abide by the agreement. The implicit message: play ball, and we won’t legislate you.
Dr. Oz was blunt about why. As NPR reported at the time, Oz said, “There’s violence in the streets over these issues,” alluding directly to the killing of Brian Thompson. “This is not something that is a passively accepted reality anymore — Americans are upset about it.”
He was certainly right about that. .But I can assure you, the industry was not moved by conscience. It was moved by fear: fear of public rage, fear of bipartisan legislation gaining momentum in Congress, fear that the social media firestorm after Thompson’s murder had permanently altered the political calculus around health insurance regulation. The voluntary pledge was the solution. Give the administration a win it could announce at a press conference. Show the public that reform was underway. Preserve the right to self-define what “reform” means.
Oz called the pledge “a step in the right direction toward restoring trust” and praised it as the kind of issue that “should be solved” by the private sector rather than government. That’s the deal. Voluntary commitments in exchange for regulatory forbearance. The industry gets to write the rules of its own accountability. The administration gets a headline.
What the “Transparency Report” actually reports
Cigna’s Customer Transparency Report, released in March, is the most polished piece of this campaign I’ve come across. It states that Cigna removed prior authorization requirements for 345 tests, procedures, and services — a change the company says decreased overall prior authorization volume by approximately 15%.
Which 345 services? The report doesn’t say. We are asked to take Cigna’s word that these were not 345 low-utilization, rarely-contested procedures that were essentially rubber-stamped anyway — that the company didn’t selectively prune the easy cases to manufacture a favorable headline number.
Here is what I know from my years in this industry: the vast majority of claims have been automatically adjudicated electronically for decades. Routine, low-cost, uncontested procedures flow through the system without human review. What gets flagged — what actually gets held up, scrutinized and frequently denied — are the expensive requests. The chemotherapy regimen. The advanced imaging when a patient’s symptoms suggest something serious. The specialty biologic that costs $80,000 a year. The complex surgery requiring detailed documentation and specialist review.
Dr. Wendy Dean, who joined us on the third episode of the HEALTH CARE un-covered Show, has a name for what this does to physicians: moral injury. Not frustration, not inconvenience — injury. The repeated experience of knowing what your patient needs and being systematically blocked from providing it, by a process controlled not by medicine but by a business calculation made somewhere far from the examining room. Prior authorization is the machine that produces that injury every single day in America.
Prior Authorization: Care, Delayed | EP 3
Prior Authorization: Care, Delayed | EP 3
A deep dive into prior authorization’s toll — from doctors to federal policy—featuring Dr. Wendy Dean, Dr. Seth Glickman and Rep. Suzan DelBene (D-WA) on CMS’s new AI-driven WISeR model.
A 15% reduction in prior authorization volume almost certainly didn’t come from those cases. It came from removing procedures that weren’t generating significant friction in the first place. The cases that destroy lives when they’re denied — those are precisely the cases most likely to remain fully subject to prior authorization review, now increasingly conducted not by a physician but by an algorithm.
And last week’s industry pledge, announced through AHIP, is careful to acknowledge as much. The new standardization framework “does not impact individual plans’ clinical policies or coverage determinations.” That sentence, buried deep in the press release, is the most important one. The pledge standardizes the form a doctor’s office uses to submit a prior authorization request. It does not change what happens after the form is submitted. It does not change Cigna’s criteria for approval or denial. It does not change who reviews the request, or how quickly, or what standards they apply.
Who verifies any of this?
The “accountability” mechanism Cigna touts in its Transparency Report is tying executive compensation to Net Promoter Score — a customer satisfaction survey the company administers itself. The company’s NPS “increased compared to 2024,” the report says, without disclosing the actual numbers or the methodology.
The report is a document Cigna wrote, about Cigna, measuring metrics Cigna selected, verified by no one outside Cigna. When I was VP of corporate communications at Cigna, my job — part of it — was to help construct narratives like this one. We knew which statistics would travel well in a press release. We knew how to frame progress in ways that sounded accountable without actually being accountable. I’m not describing bad faith, necessarily. I’m describing the ordinary logic of institutional communications, which optimizes for favorable presentation, not complete disclosure.
So here is the question I most want Cigna to answer: Would you open your actual claims data — denial rates by procedure, by condition, by demographic, by market — to independent review? Not to a consultant you hired. Not to an auditor who depends on your future business. To researchers. To journalists. To Congress. To me.
The industry reported through AHIP an 11% reduction in prior authorizations, representing 6.5 million fewer requests. That number covers dozens of health plans across hundreds of markets. There is no way to verify it: The methodology isn’t public, the baseline isn’t specified, and the mix of commercial, Medicare Advantage, and Medicaid business isn’t broken out. The denial rate — the number that actually matters — isn’t mentioned at all.
11% sounds like progress. But 11% of what, measured how, against what baseline, with what effect on patient outcomes? We don’t know, because we are not allowed to know. That’s not a transparency report.
The timing is not a coincidence
Cigna will report its first-quarter earnings tomorrow. Wall Street will scrutinize the numbers. Analysts will ask pointed questions about medical cost ratios, about Evernorth’s performance, about the trajectory toward the company’s projected $8 billion-plus in adjusted income from operations for the year. By the end of the call, investors will know roughly what they need to know about how the business is performing. The rest of us are being handed a PDF of a so-called transparency report.
The sequencing of this campaign — voluntary pledge negotiated with the administration last June, Transparency Report released in March, industry standardization announcement last week — is not a coincidence. I know what a communications strategy built around an earnings calendar looks like because my name was on Cigna’s earnings reports for 10 years. I also know what it looks like when an industry has correctly read a political moment and moved to get ahead of it.
The social media firestorm after Brian Thompson’s murder was real. The public anger it reflected is real. The industry recognized that the old business and communications strategies — deny, delay, deflect — were endangered in a world where every patient with a denied claim has a platform and an audience. The response has been sophisticated: genuine enough to be defensible, incomplete enough to be sustainable.
On Thursday, Cigna’s executives will take questions from the analysts who follow their stock. They will speak with precision about earnings, margins, and growth because Wall Street demands it.
Patients deserve the same, but they’re not getting it. What Cigna has published isn’t a transparency report. It’s a press release with better production values.
HENRY KOTULA 