Are health insurers knights, knaves, or pawns?gettyThe British economist Julian LeGrand suggested that public policy is grounded in a conception of humans as "knights," "knaves," or "pawns. Human beings are motivated by virtue (knights) or rigid self-interest (knaves), or are passive victims of their circumstances (pawns). A society's view of human motivation influences whether it builds public policies that are permissive, punitive, or prescriptive.Le Grand's observations were drawn from his studies of British social welfare policy and civil servants but could aptly be applied to health insurers and their role in the US health care system. Many health care debates-especially those relating to health care financing, quality, and education-implicitly prescribe a view of health insurers and their underlying motivations. This framework has previously been applied to physicians, patients, and pharmaceutical companies.Depending on the perspective, health insurers operate for the betterment of society or their own selfish gain; or their actions are defined more by external rules, regulations, and competitive positioning. The role of health insurance companies in US society has been actively debated in US society since the tragic murder of UnitedHealthGroup CEO Brian Thompson.I explore the ways in which health insurers are variously represented as knights, knaves, and pawns in public discourse and relate the importance of designing policies that match the true motivationswhatever they may be.Some health insurers perceive themselves as having knightly intent.gettyHealth Insurers as KnightsIf a society conceives of health insurers as ever well-intentioned knights, it places stewardship for the health care system firmly in their hands. Health insurers can be trusted to use and deploy resources wisely, minimize waste, and look beyond their narrow interests to protect the system as a whole. They are enablers of distributive justice by spreading risk across populations of health and sick people. They are the ultimate champion of the patient and the policies they implement through utilization management are designed to protect against fraud, waste, and abuse and ensure that care is delivered in accordance with evidence-based guidelines. Health insurers negotiate with health systems to reduce prices for patients and ensure broad access to care for a wide swath of the population. They operate to promote affordability, access, and quality and any financial gain is secondary. Health insurers identify and address quality issues and partner with doctors and health systems to improve care.Some perceive the role of health insurers as knaves.gettyMORE FOR YOUHealth Insurers as KnavesIf a society conceives of health insurers as knaves then policy, management, and educational efforts are designed to combat and work against health insurers, not with them. Health insurers are interested in themselves and their financial well-being first and their patients second, if at all. They deny care and restrict access to enhance profits. They prompt aggressive coding behavior to maximize revenue and government payers and they use their vast market power to underpay doctors and hospitals. They aggressively lobby and donate to politicians to preserve their ability to raise prices on their products and gouge the public. The health care system works in spite of health insurers not because of them. Policies and regulation must guard against their malfeasance, and the public must be protected by intense regulation and report cards. Without such regulation, health insurers will do everything the can collect as much as they can in premium revenue and pay as little out as possible.Some conceive of the role of health insurers as pawns in a more complex system. gettyHealth Insurers as PawnsIf a society conceives of health insurers as pawns, then efforts are applied to building systems to ensure that health insurers do what is right for patients and physicians because they cannot be trusted to do so on their own accord. Left to their own devices, health insurer behaviors are unpredictable. The health insurer is merely a function of the regulatory environment in which he it operates; accordingly, health insurers must be given guidelines to follow and policy-makers and regulators must decide priorities. Health insurers do not have any intrinsic orientation towards quality, but participate in quality programs because employer customers and require that they do so. They merely respond to regulatory requirements and expectations. The role of health policy and regulation for the pawn health insurer is to guide their every behavior because they lack individual agency, judgment, and moral compass to reliably do what is right for patients, doctors, or society.ImplicationsLe Grand's work on post-World War II British social policy found that perceptions of human motivations gradually transformed, with the prevailing view of the typical British citizenry morphing from knight into knave as the costs of maintaining an expensive welfare state increased.US perspectives on health insurers have undergone a similar transformation with the increasing costboth to taxpayers and to individual patientsof health care delivery. As health insurer behavior has been tied to these rising costs and increasing scrutiny has been applied industry behaviors, policy discourse increasingly reflects the perspective that health insurers are an obstacle not an enabler to a functioning health care system. Rather than being counted on to do the right thing, health insurers should be subject to intensive regulation to protect the public.These views are grounded in evidence of massive, increasing health insurance industry profits. The modern health insurer is regarded as either a knave or a pawn and is seldom regarded as a knight. But the evidence that has led to distrust of health insurers does not apply universally and some companiesin particular many not-for-profit onesstill aim to serve people communities. How can society be sure not to undermine those motivated by doing the right thing while guarding against those motivated purely by self-interest and profit?Insurers have been enablers of value-based models of health care payment such as accountable care organizations, the patient-centered medical home, hospital-at-home, and senior-focused clinics. In these examples, insurers are supporting a more progressive model of care delivery that enables responsible resource utilization. Applied effectively, these models improve individual and population outcomes.Still, it is perhaps the knavish conception of health insurers that makes these models more the fodder of modest pilot projects and demonstrations than models that are rapidly adopted and widely disseminated. With massive public discontent and a new presidential administration, could policy and regulation be accelerated to further force the health insurance industry in the direction of the models that more align with patient outcomes and stewardship of society?Le Grand offers an important lesson and warning: it is critically important to understand and get "true motivations" right. Disaster may follow if persons largely of a knavish quality are treated as knights; but the same may be true for "policies fashioned on a belief that people are knaves if the consequence is to suppress their natural altruistic impulses and hence destroy part of their motivation to provide a quality public service. Le Grand further warns that policies that "treat people as pawns, may lead to de-motivated workers..and causing adverse outcomes for the policies concerned; while policies that give too much powermay result in individuals making mistakes that damage their own or others' welfare."Policymakers would be wise to heed Le Grand's advice and carefully consider the motivations and behaviors of health insurers. For their part, in this time of profound turmoil, health insurance industry leaders must thoughtfully consider whether and how they contribute to the perception that they are knights, knaves, or pawns