Matt dives into a specific healthcare topic to help those in the industry, and those outside of it, better understand the market drivers causing today’s healthcare challenges.

Blue Shield of California positions itself as a mission-driven insurer. The organization voluntarily caps its net income at 2% of revenue and returns anything above that to customers and communities. That sounds like a company that prioritizes patients over profit. Read their mission report, and you see language about affordability, access, and a healthcare system worthy of its members.

Now look at the operating reality. In 2024, Blue Shield posted $103 million in net income on $27.4 billion in revenue. The company serves 6 million members and employs over 6,500 people. According to a Milliman analysis comparing for-profit and nonprofit insurer financials, nonprofit health plans averaged 0.7% net income as a percentage of revenue over the last three years, while for-profit parent companies averaged 3.2%. Blue Shield's 2% cap places it right between those benchmarks. A 2% margin on $27.4 billion in revenue still produces nine-figure profits. Calling that "nonprofit" requires a generous interpretation of the word.

Meanwhile, California's Department of Managed Health Care issued seven enforcement actions against California health plans for wrongful denials based on medical necessity in 2025, totaling $1.165 million in fines, with Blue Cross and Blue Shield plans bearing significant weight. In 2022, the DMHC overturned 55.9% of medically necessary Internal Medical Reviews, and Blue Shield reversed its prior denial in only 18.8% of appeals before it reached that stage. Blue Shield denied part of a San Francisco firefighter's cancer treatment, generating enough public outrage to trigger a government hearing at City Hall. A class action lawsuit alleges Blue Shield and Magellan Health maintained a "ghost network" of mental health providers who either do not exist, do not accept the insurance, or refuse new patients for months.

Every advocacy professional who has worked with a major payer knows the pattern. The public affairs team talks about partnership. The medical affairs team talks about patient-centricity. The compliance team talks about transparency. And the claims processing department operates on a completely separate set of priorities.

ELAVAY measures this exact dimension. We assess trust, responsiveness, commitment to patient outcomes, and quality of working relationship between advocacy organizations and the companies that claim to serve them. Companies that score highest on the ELAVAY INDEX share one trait that separates them from everyone else: their internal operations match their external messaging. When an advocacy partner calls, someone picks up the phone. When a formulary decision affects patients, the advocacy team has a seat at the table before leadership makes the decision. When a denial pattern emerges, leadership addresses it without waiting for a regulator to force their hand.

The organizations that score lowest share one trait too: they invest heavily in the language of reform while resisting every mechanism that would hold them accountable to it.

I have spent two decades in this space. I have watched the insurer playbook evolve from ignoring advocacy entirely to co-opting its language as a defensive strategy. The pattern runs like this: CEO publishes thought leadership on transparency. Organization resists external audits of denial rates. Claims processing timelines remain opaque. Executive compensation escalates without any tie to patient outcome accountability. Public responsibility committees exist on paper. Operational behavior tells a different story.

Wendell Potter, the former CIGNA executive turned industry whistleblower, documents this dynamic extensively through his Health Care un-covered newsletter. Potter calls attention to out-of-control profiteering in U.S. health care and traces how insurers deploy reform language as a brand strategy while lobbying against the very policies that would enforce actual accountability. The gap between what the CEO says at the podium and what the claims department actually does represents the single biggest credibility crisis in the payer industry today.

Blue Shield of California lost its exemption from California state corporate income tax in 2014.
The organization still operates as a nonprofit. That distinction matters because it shapes public perception while leaving the underlying business model largely intact. When an insurer wraps itself in mission language and then denies a firefighter's cancer treatment, the advocacy community does not forget. We measure that gap. We quantify it and we publish it.

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ELAVAY top-tier companies do three things the rest refuse. They submit to external measurement of their advocacy relationships. They fund the advocacy function with real budget authority. And they tie executive incentives to patient-reported outcomes.

Organizations that improved their ELAVAY scores year over year share specific, observable behaviors: they increased advocacy team headcount, they elevated patient voice in formulary decisions before regulators required it, and they invested in advocacy infrastructure before anyone asked. These companies treat advocacy as a strategic function, not a cost center dressed up with mission language. They give their advocacy leads direct access to the C-suite. They report advocacy outcomes in board meetings alongside financial performance. They build long-term relationships with patient organizations based on mutual accountability rather than transactional sponsorship.

The difference between a top-tier ELAVAY performer and a bottom-tier performer has nothing to do with size, revenue, or market share. It comes down to whether the company believes accountability produces better outcomes or simply produces better press releases.

If you lead an advocacy function at a health plan or work with insurers as a patient organization, you already feel the gap between what people say in meetings and what happens after you leave the room. ELAVAY quantifies that gap. The 2026 report is out now.

Contact [email protected] to sign up for our webinar sharing the latest topline findings from ELAVAY on June 30th, or take the Advocacy Influence Diagnostic at aid.elavay.com to measure whether your organization's advocacy function holds real internal influence or occupies a line on the org chart. Archo works alongside advocacy teams at health plans and patient organizations across the country: for many, that looks like weekly or monthly touchpoints where we guide strategy with best practices while advocating for the advocacy function internally, on your behalf.