In 2017 we'd just had a crazy election, the ACA was a thumbs up away from John McCain from going away and we thought the elimination of Cost Sharing Reduction funding would blow everything up. That was until a clever actuary realized we could raise prices on silver plans and save everything!

On today's episode we explore what happens we explore the mechanism that saved the ACA and at some point, when fueled up with additional steroids from covid funding, almost blew everything up! Welcome to our episode on Silver Loading!

In this episode of Unintended Consequences, Jesse Hendon walks through why the ACA had to exist, why it chose a market-based solution instead of socialized care, and how a series of well-intended design choices reshaped the incentives of the entire system.

This is the story of underwriting before 2010, the introduction of guaranteed issue, the 80/20 Medical Loss Ratio rule, age-rating compression, and the bet on the “Young Invincibles.” It’s also the story of what happened when that bet didn’t pay off.

By the end of the episode, you’ll understand why underwriting never disappeared — it just changed form — and why narrow networks, prior authorization, and utilization management became the new tools of control.

This is Episode 1 of a three-part series on how healthcare policy changed the system’s incentives — and why those incentives still shape coverage, cost, and access today.

This episode traces the changing of the Medicare Advantage incentive machine. When risk scores, star bonuses, and vendor ecosystems pushed the system past sustainability, CMS responds with course correction: payment model rewrites, diagnosis weight reductions, compliance tightening, audit pressure, and litigation. The bonus economy is changing. When the stars change how the pay, the system is forced back to reality, and the industry has to relearn the difference between healthcare and optimization.

This episode explains how Medicare Advantage shifted from care delivery to score optimization. Star Ratings were introduced as simple transparency tools, similar to reviews, not outcome measures. When money was tied to them under the ACA, they became economic levers. Combined with Risk Adjustment, they turned sickness into revenue and documentation into strategy. Plans built vendor ecosystems to optimize metrics, not medicine. What began as quality measurement became performance theater, market consolidation, and a system vulnerable to fraud, waste, and abuse. This is the moment Medicare Advantage stops being healthcare infrastructure and becomes a scoring economy.

This episode unpacks how this payment model changed everything for American seniors, leading to some surprising outcomes.

The moment healthcare became a third-party transaction, cost discipline disappeared—and it never returned.

In this inaugural episode of Unintended Consequences, we track the origin story of the American health insurance crisis. It wasn't a master plan; it was a wartime workaround that hardened into infrastructure.

We cover:

• The Wartime Decision: How WWII wage controls accidentally invented employer-sponsored insurance.

• The Third-Party Problem: Why prices skyrocket when the patient isn't the payer.

• The Risk Pool Trap: Why tying long-term health risk to short-term employment guarantees friction (and higher costs).

Nothing about your health changes when you quit a job, but your access to care does. That outcome wasn’t planned. But it was inevitable.