How One Company Gamified Health Insurance

Note: This transcript has been created with a combination of machine ears and human eyes. There may be small differences between this document and the audio version, which is one of many reasons we encourage you to listen to the episode above!

Dan Gorenstein (DG): Hey, Dan here. 

It’s almost that time of year when employers tell their workers what’s on tap for their health insurance in 2026. 

Which doctors are in, which drugs are out and how much it’s going to eat out of their paychecks every month.

But what if, instead of making those tough calls behind closed doors, companies opened up those doors and invited employees to weigh in?

That’s the unusual approach taken by one company we profiled back in 2024. 

This week, as health care costs continue to climb, we revisit that story.

ORIGINAL STORY:

DG: Health insurance premiums eat up nearly 20% of every employee’s paycheck in the U.S, on average and those costs continue to climb.

There’s an avalanche of reasons. Higher hospital bills. Expensive scans. Pricey new drugs for cancer or weight loss. 

These costs force companies to make tough choices about what benefits to include in the health plan – and which to leave out. Executives usually do the deciding.  

But an employer in Maryland thinks there’s a better way. 

Janet McNichol: We’re not the kind of place where one person sits by themselves and makes decisions that impact a lot of people.

DG: Today – employees – not executives – design their organization’s health plan. 

From the studio at the Leonard Davis Institute at the University of Pennsylvania, I’m Dan Gorenstein –  this is Tradeoffs. 

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DG: Summer – if you’re lucky – is the season for vacations, pools and barbecues. 

For the staff of the American Speech-Language-Hearing Association, or ASHA, it’s also the time to play a game called “Benefit Builder.” 

Over the last few months, 140 employees, about half of the staff of this association in Rockville, Maryland divided up and played in small groups.

They stepped away from their regular work to spend a few hours debating how to spend the organization’s health care dollars. 

Evan Reid (ER): I didn’t expect I was going to have fun designing our health insurance plan.

DG: That’s 40-year-old Evan Reid – head of analytics at ASHA. 

On this particular Monday morning in July, Evan and seven coworkers spend a little time on their own, creating the perfect health plan for themselves and their families. 

Evan has two young kids. 

For him good insurance means dental care and low out-of-pocket costs for doctors visits or tests. 

His colleague, Jeanette Janota, a senior research associate, wants something different.  

Jeanette Janota (JJ): I’m elderly, I need health care, and I’m willing to pay for it. 

DG: Jeanette’s 82 and would like cutting-edge medicines if she needs them, plus a wide choice of doctors and hospitals. 

JJ: I have a dermatologist, an obstetrician gynecologist, a cardiologist, an orthopedist, a, you know, you name it, and I’ve got it. 

DG: Once everyone designs their dream plan, they turn their attention to their colleagues.

Each player picks a card to read out loud  – hypothetical scenarios based on new benefits ASHA is actually considering.  

Julia Reilly-Edwards, another data scientist, reads hers.  

Julia Reilly-Edwards (JRE): I have pancreatic cancer. I have not responded well to treatments, and the prognosis is grim. My doctor said it wouldn’t hurt to try a drug that’s only been approved for bowel cancers. It costs $8,000 a month and would only be covered with the highest-level prescription benefit. I know it’s not a cure, but I’m hoping it may give me a few more months with my loved ones.

DG: The question here is: Do you personally want to pay higher premiums every month so that a coworker could get access to what could be life-extending care if they needed it? 

It’s just one of several dilemmas this group thinks through together as they enter the next phase of the game. 

To ratchet up the stakes, Janet McNichol, ASHA’s head of Human Resources, directs the group to another part of the room, and hands out 70 poker chips.

JM: So what we’re going to do next is gather around the large game board over here. 

DG: Janet created the game board, where coverage for things like surgery, prescription drugs and mental health each costs a certain number of chips. 

The more generous the coverage, the more poker chips that option costs.

Here’s where it gets tough: The group must come to a consensus on where to spend the chips. 

JM: If you were to buy the whole health plan, it costs 92 chips. You have 70 chips. So you’re going to have to do a little bit of prioritizing. What services and features do you want and what are you willing to give up for that?

DG: Janet says this is the most important part of the game – the most realistic.  

ASHA designs its own health plan – rather than buying an off-the-shelf policy from an insurer and Janet faced these decisions for years on her own.

Back when she first got into the business in the 1990s, she was comfortable making choices when health benefits seemed more straightforward. 

JM: Are we going to cover birth control? And I’m like, yeah, 80% of our population is women. We want them at work. So of course we will, you know. Are we going to cover Rogaine? Hair? Not necessary. We don’t need to cover Rogaine. The decisions weren’t that difficult.

DG: But over the last 30 years many new tests and treatments emerged. And health care spending has tripled. 

That squeeze has put Janet and other benefit leaders in a tight spot.   

ASHA’s health care budget for 2025 is about $4 million. Janet explained that covering every option on the board would take another million-plus. 

JM: Obviously you have to make tradeoffs, you can’t pay for everything because it is really expensive. 

DG: Things came to a head for Janet in 2016. She was sitting in a room with an insurance agent who was firing questions at her. 

How much physical therapy do you want to cover, When do you want to cover an MRI?  

As she weighed each question, Janet pictured paychecks shrinking. 

And it wasn’t just the expense. Health care was becoming more controversial. 

What about gender affirming care? What about abortions?  

JM: We’re making all these decisions and we get to that one. And I was just like, whoa. I almost like, didn’t want that responsibility for making that decision for everybody else. 

DG: She wanted to know what her employees wanted. What health care did they most value?

JM: That was a moment where I thought, there’s, there’s got to be a better way to do this. 

DG: Most companies would just email a survey, but Janet wanted to go deeper – to get workers to really grapple with the limits she faces devising the company plan. 

JM: I’m looking for people to have a dialogue, and weigh the trade-offs between one choice and another choice. Then you’re able to come to some sort of consensus that everybody accepts and feels good about. 

DG: Turns out there was some science behind Janet’s instinct. Research shows that when employees or patients are included in decision-making, they tend to be happier with the final outcome. 

JM: When you’re making value-laden decisions, how you decide matters.

DG: Now, Janet loves the nitty gritty of health care economics.

She actually discovered this game when she was taking a health econ class a few years ago. 

Scientists at the University of Michigan and the National Institutes of Health had created the game in the 1990’s. 

The game was simple to play. No jargon or background in insurance required.

She thought it could be a good fit for ASHA.

JM: People here care about one another. They’re kind.  We team up on a lot of things. People work together routinely, so I do think it fits with our culture.

DG: Janet has asked workers to play the game twice over the last eight years. One of this year’s toughest questions: whether ASHA’s health plan should cover drugs like Wegovy for weight loss.  

Tavril Saint Jean, a senior research associate, picks up a game card and begins to read:

Tavril Saint Jean: I weigh about 300 pounds. I am pre-diabetic and at risk for heart disease. I’ve tried restricting food, but I always feel hungry. My doctor suggested I try Wegovy. It costs $1,400 a month.

DG: Jeanette Janota likes the idea.  

JJ: Personally, I wanted to have that option.

DG: Evan Reid, the guy across the table from her? He isn’t so sure. Because, remember, the team has only 70 chips to spread around the whole board.

ER: The question is like, do you need that coverage for the entire 300-person staff at the cost of six chips?  

DG: Evan’s kids are 6 and 11. He’d rather spend some of the money on their braces.

ER: I still very much want to make an argument for orthodontic care, which is going to be a large out-of-pocket expense for a decent chunk of staff.

DG: These debates are exactly what Janet wants to happen. It’s the first step to finding a compromise. 

After the break, what benefits the group picks and whether this game might work for other employers.  

MIDROLL

DG: Welcome back.

Before the break, we heard about how one employer is using a game to help employees design their own health plan.

Tradeoffs Reporter Alex Olgin found this story and joins me to talk about it. 

Alex, first of all, how did you even hear about this –  ASHA turning over these decisions to their employees. Let alone through a game. 

Alex Olgin (AO): I was doing research on an issue that employers struggle with: Are they going to cover new weight loss drugs like Ozempic and Wegovy? 

And as we’ve reported before, Dan, the drugs in this class, known as GLP-1s, are hugely expensive – and a key reason health care spending has shot up.  

That’s led some employers to drop coverage of the drugs – leaving workers who were already on the medicine in a really tough spot. 

News montage: North Carolina state employees will no longer receive reimbursement for GLP1s. // But now the University of Texas System says it will end insurance coverage for Wegovy.

AO: The problem is employees can suffer when companies make these sudden cost-cutting choices. 

So what ASHA is doing, Dan, is flipping the script and giving the workers more power, basically they use the game to ask this question. 

‘Do you guys want to pay more in premiums every month so any of your coworkers who want these expensive weight loss drugs can get them?’

DG: Right, so Alex, I know we talked about this in the first half of the show: what did that group of 8 ASHA workers decide about Wegovy? 

AO: So this was interesting! 

The employees basically said they weren’t willing to pay more to cover the drug. Nor were they willing to cover it at the expense of cutting coverage in another area like mental health or hospital care.

DG: And I’m curious –  did these folks agree fairly easily on other benefits?

AO: Some stuff, yes. 

The team quickly settled on paying for the most generous emergency care, primary care, mental health and dental – including braces.

DG: (chuckles) I can picture Evan’s face with a huge smile plastered on it. 

AO: Yes, he was grinning ear to ear. And as you know, Dan, I’m married to a dentist so he was also happy to hear that as well. 

DG: OK, but a risk of this game – I’ve got to imagine – is that employees could get mad or defensive when they disagree. Did that happen? Were there any fights? 

AO: No fist fights. But there was a pretty contentious debate in this group  — for almost an hour – about doctors and hospitals.  

And Janet would say that’s great.

She loves these disagreements – they are just the kind of healthy clashes she wants her people to have about their health insurance. 

It’s a sign she thinks that the game is working. The important thing is how the employees resolve those conflicts.

DG: Right. So you said there was a conflict about hospitals. What was that about?  

AO: Basically, some employees like Evan, initially thought it best to go with a plan that made it cheaper to go to hospitals with higher safety marks. 

But Jeanette disagreed.  Over the last few years she had both of her shoulders replaced. 

JJ: If you have regular surgery like a replacement for a shoulder, you find your doctor and you go where that doctor goes – to his hospital. You can’t pick your hospital. 

AO: Listening to Jeanette’s experience had a big effect on Evan.

It changed his mind.

Here’s what he told me after the game.  

ER: I think Jeanette probably had some of the most, um, poignant examples of where what we thought was like an ideal policy from a health care standpoint, just like didn’t really meet the real world well. 

DG: Getting people to change their minds is big! I can see that’s a real strength of this game. 

But practically speaking, Alex, the group has a limited number of chips how can they afford everything they are saying yes to?  

AO: You’re right. With 70 chips they can’t. 

They wrestled with that for more than an hour, and ultimately decided it was so important to the group to be able to go to any hospital that they did something Janet’s never seen before. 

They agreed to each forfeit a bigger chunk of their salary to buy more chips.

Here’s how the discussion went. 

Employee chatter: I propose we buy four tokens for hospitalization and surgery. 

How much is that again?

$800 a year per person? 

16 bucks a week per person. 

I would be okay with that.

AO: That’s the sound of Janet McNichol plunking down four more poker chips.

Now, Janet’s run a dozen more rounds of this game this summer with various groups of employees.

JM: I’ve never seen a group that bought that many chips before. Because they bought four, highly unusual. 

DG: Wow – So, faced with limits and disagreements, their compromise was forking over more money from their paychecks. That’s got to be “peak game!”  

AO: It definitely is. Janet would tell you it was grappling with the decision together that was key. This is just one thing she likes about this game. 

In fact the last time she ran a version of the game was in 2017, and 85 % of employees liked the result – were happy with the overall decisions. 

She’s found that across the organization when people have this kind of direct input into the health plan they are more willing to accept limitations or higher costs.

DG: That sounds consistent with the research that we’ve talked about.

And this game also seems like it can help employers figure out a way to design insurance plans that get more worker buy-in. 

This is at a time when – you’ve got weight loss drugs forcing employers to think long and hard about what to do.

Are other companies out there using this as a tool, Alex?

AO: I’ve asked around. And I’ve only heard of a local government and school district using it for this exact purpose. 

To find out why I called Paul Fronstin. He’s a health economist at the Employee Benefits Research Institute. 

He says there are just much easier ways to get employee feedback.  

Paul Fronstin: Some employers do surveys. Some employers will do focus groups. It is rare for an employer to go to this length.

DG: I get it – I mean, just to start it takes several hours of every employee’s time to do this.

That’s time that they’re not on the job.  And I imagine this must be a ton of work for people in Human Resources – like Janet.

AO: Yeah, starting in January, Janet has to figure out what questions to ask employees. 

Then she has to do the math about how much each benefit would cost. And more math about how much each chip is worth. 

After running different rounds of the game all summer she then tallies results from all the groups.

DG: Super time-consuming. Is that the big downside of this game? 

AO: It’s not the only one. Employers have to be willing to give up some control to their employees. That’s tough.

And, every game could be opening up a can of worms – inviting conflict between workers.  

That’s why, Dan, one of the ground rules is workers must come to a consensus. Which means they are forced to listen and horse trade.  

DG: OK, so after all this compromising from this group of employees and a dozen others, what is the final outcome for the health plan? 

AO: By and large there was consensus among the groups, even on the thorniest questions. 

They all decided not to cover Wegovy, but to cover abortion and infertility treatments.

However, on that big question about hospital choice that Evan and  Jeanette’s group spent so much time debating – where they decided to buy extra chips.

Workers overall decided on something different. They chose the option that makes care cheaper at hospitals with higher safety marks. 

So that’s how Janet will structure the final plan.

DG: What did Janet think of how this all turned out at the end of the game?

AO: Here’s what she told me. 

JM: I can sleep at night because I’m not making these value-laden decisions for everybody else.

AO: She says, for her, in the end the details of the plan are less important.

What matters more are the honest conversations about health care and the way the game helped people empathize with their colleagues. 

It really boosts morale.   

Twenty-seven-year-old Julia Reilly-Edwards was in Jeanette and Evan’s group.    

She told me the game helped her understand people who’ve had different health experiences across generations.

JRE: I thought just the overall, ability of the group to have, like, a really personal kind of discussion about it, but one where we were open to listening to each other… I thought was really refreshing and very important.

JM: This is the kind of thing that gives me hope for the world. 

AO: That’s Janet, of course, and she says that sentiment from Julia is why the game is worth all the trouble.  

JM: Like, people can make these decisions together. And if you build a process for dialogue, then people can engage and they can think deeply about things and they can change their mind or see things from a different perspective. And I think they can generally come to an agreement on things.

DG: A life lesson that goes far beyond health insurance,  Alex, clearly.  Thanks for your reporting on this. 

AO: You’re welcome Dan. 

DG: So, this year’s game is done. But Janet is already thinking about the next version. 

At the top of that list is another fertility benefit – Should ASHA pay for employees who want to freeze their eggs?

Right now, about 20% of companies pay for the procedure and egg storage. 

But every appealing new benefit you add comes at a cost as the game makes plainly clear.

UPDATE:

DG: Since this episode first aired, employers’ health costs show no signs of slowing.

Analysts expect spending to rise by 8% next year.

As for Janet McNichol, she says as far as she’s heard, employees are happy with the choices they made.

And, perhaps even more important to her, they’re happy with the process.

A recent survey that Janet ran found that more than 80% of employees said they feel the organization values their views on health benefits.

In her spare time, Janet says she’s working on a how-to guide for other employers. 

I’m Dan Gorenstein. This is Tradeoffs.