The answer Ann Wilson (pictured) gives is, by her own admission, unpopular. When asked what single systemic issue she would fix in American employee benefits, the Hub International executive vice president doesn’t point to pharmacy benefit managers, drug manufacturers, or insurance company profits. She points to something far more uncomfortable: the American public’s escalating use of healthcare itself.
“Healthcare in the United States is a fairly simple mathematical equation: price equals cost multiplied by utilization,” Wilson says. The fact of the matter is we’re using an enormous amount of healthcare, which is significantly contributing to the overall increase in cost.”
Wilson’s perspective is informed by decades of experience and a track record of helping clients anticipate emerging challenges, including identifying rising GLP-1 medication costs that ultimately saved one client approximately $100,000 in drug spending. Her journey through the worlds of contract law, federal regulation, and human behavior began with a newspaper classified ad and a young child at home.
Wilson’s route into employee benefits was anything but linear. As a political science major at the University of California, she was pre-law, eyeing a career as an attorney. A junior year internship at a law firm changed everything.
“I quickly realized that I did not want to be an attorney, which was a significant change,” Wilson recalls. “I didn’t really understand at that point what I was going to do.”
She spent six years in project management, negotiating contracts on behalf of an employer while growing her family. When that role lost its appeal, she looked for something adjacent to law without the courtroom. This was the era when job hunting meant scanning newspaper classifieds, and one particular listing caught her eye: COBRA administrator.
Federal COBRA (The Consolidated Omnibus Budget Reconciliation Act) is a federal law that allows for healthcare extension and benefits. “I thought, that’s related to federal law, that would be interesting. And that is how I ended up in benefits,” Wilson says. “At that point I was working part time because I had a young child, but I literally fell into it, like many people do.”
Wilson began her career at Benefits Resources before moving to Intercare Insurance Solutions. Intercare was later acquired by HUB International, bringing her into one of the industry's major players. Looking back, she notes that her pre-law background proved even more valuable than she had anticipated.
“What we do in insurance is really a combination of contract law and navigating legal requirements,” Wilson says. “It genuinely helped that I had a pre-law background. A lot of people find it intimidating, but that’s essentially what we’re doing. We’re selling contracts and assisting clients in navigating state and federal regulations.”
Wilson’s Power Broker recognition stems from work that exemplifies the investigative, data driven approach she’s cultivated over her career. The story begins in 2023, when GLP-1 medications were still an emerging category most benefits professionals weren’t closely tracking.
GLP-1 drugs like Trulicity had been available for diabetics for years, used as escalation therapy with little fanfare. But Wilson and her team noticed something shifting in the data for their self funded clients, employers who pay their own claims and essentially function as their own insurance companies.
“Back in 2023, we were noticing that interest was starting to build in the public conversation around those drugs that had been approved for diabetics,” Wilson says. “Part of our process was doing the investigative analysis with our clients’ claims data to understand what had been approved on their formularies and how these drugs were being accessed, even before any attention was being paid to the weight loss versions hitting the market.”
At that point, formulary controls were limited or nonexistent. The drugs had made their way onto formularies without much scrutiny because they were already FDA approved, just for a different function. Wilson’s team noticed utilization quietly escalating.
“It was really all about data analysis, using the tools we have available through Hub and through our carrier partners to understand what was happening with utilization and where it was projected to go,” Wilson says. “We ensured proper controls were applied to access those medications and brought that data forward to the client.”
The intervention came before high profile celebrities and influencers started discussing Ozempic and Wegovy on social media, before the mainstream explosion of GLP-1s for weight loss. By delivering early insights, Wilson’s team helped the client avoid what would have become runaway costs.
“As we’ve seen between 2023 and 2025, the use of these medications has absolutely exploded,” Wilson says. “By delivering early insights about their own data and helping them understand where things might actually end up, we were able to provide them with that savings and prevent a situation where utilization would have run rampant.”
How were employees accessing these drugs in the first place? Wilson is quick to clarify that it wasn’t illegal activity, just a gap in oversight during a transitional period.
“It wasn’t a loophole in the sense that anyone was doing something illegal,” she says. “When the medications were initially approved, diabetic versions came first. Reformulations at different dosages specifically for weight loss came later. In between, the weight loss versions sat on formularies without anyone fully grasping the impending impact.”
Then celebrities and influencers discovered them. Doctors began writing prescriptions for the diabetic versions to assist with weight loss, so called off-label use. Wilson and others in the industry started seeing utilization spikes and went back to pharmacy benefit managers to analyze the data.
“We started finding those people and turned that off quickly,” Wilson says. “The pharmacy benefit managers subsequently added prior authorization requirements and clinical criteria for diabetic use prescriptions.”
Today, employers can still choose to offer GLP-1s for weight loss. Some states legally require fully insured employers to cover them. But requirements have become more stringent: clinical diagnosis of obesity, working with health coaches, meeting standards around exercise or diet modification.
The sophistication has increased dramatically in just two years, but so has the recognition of the cost burden. Many self funded clients are now removing GLP-1s for weight loss entirely. Starbucks recently announced it was dropping coverage. Wilson notes that individuals can still purchase the medications directly from manufacturers or other sources with a prescription, they simply bear the cost themselves rather than having their employer cover it.
The GLP-1 story is playing out against a broader backdrop of transparency regulation. New reporting and transparency requirements for pharmacy benefit managers are coming in 2027 and 2028, following earlier regulations around medical procedure cost transparency.
“The idea is to pull back the curtain and allow consumers to understand what their end cost is going to be for any given service or medication,” Wilson says. “That’s not as straightforward as it sounds.”
Even with cost comparison tools available on every insurance carrier’s website today, engagement remains exceptionally low. Most people follow their doctor’s recommendation without questioning it, potentially unaware that the physician may be referring them to an imaging center they own or a hospital system providing them a financial benefit.
The medication side is even more complex. Wilson describes pharmacy benefit management as “one of the most convoluted, entangled fulfillment processes in the world.”
“The layers of profit built into the system are very deep, sedimentary layers of profit throughout the entire chain,” Wilson says.
She walks through the entire supply chain, starting with drug manufacturers that are for-profit entities demanding returns on 20 plus years of research investment. They’ll extend patents through changes to medications or delivery systems. Everyone downstream layers in their own profitability requirements. The big PBMs, CVS, Optum, Express Scripts, Anthem’s Carelon, are corporate giants with millions of shareholders and prominent positions in the stock market.
Wilson offers a pointed observation about where those profits ultimately flow.
“When I talk to people who are upset about the cost of medications, I ask them to look at their 401(k), their retirement account, or their stock portfolio, and see if they have any financial interest in any of these companies they’re talking about,” she says. “In a way, many of us are benefiting if we’re participants in the market.”
The new regulations prohibiting certain profit mechanisms, like pass through pricing, face a fundamental challenge. PBMs are companies with fiduciary obligations to shareholders and boards of directors.
“If you take something from over here, it just gets moved over there in a different form,” Wilson says. “If you’re a company with millions of shareholders and obligations to a board of directors, you’re going to find a way to move those dollars from one line item to another. It’ll just appear as a different contract line item than where it sits today.”
There’s also a significant education gap, particularly among smaller employers who lack access to the data and levers available to self funded organizations.
“Sophisticated, self insured clients have exposure to more information and more levers available to manage their programs,” Wilson says. “But there is still, essentially, an oligarchy in this space.”
She notes that the big three PBMs handle the vast majority of clients and commercially fully insured programs. All of them have combined with insurance companies themselves: UnitedHealth Group owns both UnitedHealthcare and Optum, Aetna and CVS are under the same umbrella, Cigna and Express Scripts likewise.
“When an insurance company owns its own pharmacy benefit manager, you again have that profit layering built in between their own business units,” Wilson says.
The average employer is small to mid sized, buying a contract and trying to find something reasonable for their budget. If they’re fully insured, they don’t even receive the claims data that would allow deeper analysis. Most consumers have no idea how any of it works, and even in high deductible health plans where people bear more upfront costs, most don’t shop for healthcare.
“Your doctor says you need a shoulder X-ray and here’s the order, and the person just goes,” Wilson says. “They don’t stop to think about whether there’s somewhere else in the area that might offer it for less.”
Drug spend represents somewhere between 25% and 40% of total employer plan spend. The majority is still on the medical side, but pharmacy is inflating faster. Medical inflation is running around 8.5%, already elevated, and pharmacy is running higher.
This year has brought a notable shift in the benefits landscape. Wilson describes it as a period of employers pulling back after years of expansion.
During COVID, employers wanted to hold things static to avoid adding disruption. Coming out of the pandemic, intense market competition for employees drove benefit enhancements: extensions of paid family leave beyond legal requirements, more generous parental programs, infertility benefits, expanded mental health programs, lifestyle spending accounts funding discretionary dollars for wellbeing.
Now that’s contracting. Employers face elevated cost trends that have been sustained for nearly three years post COVID without falling away. Broader inflation across other business areas is compressing profitability.
“The easiest things to pull back on are those that were added most recently,” Wilson says. “GLP-1s for weight loss are a perfect example. They contributed significantly to cost escalation, there’s no federal mandate to offer them, and while there can be disruption within a particular employee population, they represent a relatively easier lever to pull back on.”
Some large employers have also reduced expanded parental leave programs in 2026. For small to mid sized employers, the struggle is even more acute because they purchase insured products without the same range of options.
“What we’re seeing now is employers pushing more of the cost burden onto employees themselves: higher payroll deductions, and plan designs that require higher deductibles and copays,” Wilson says. “Employers simply cannot continue to absorb these increases year over year when every other area of their business is being compressed.”
Technology, particularly artificial intelligence, is advancing rapidly in some areas of the benefits space while meeting significant resistance in others. Wilson sees two distinct arenas.
The employee experience, how people interact with employers through technology when making coverage decisions and going through enrollment, is expanding and changing quickly. Decision support tools have made real progress, and AI integration is accelerating further development.
Healthcare delivery itself is far more complex. AI is being used for administrative tasks and first level customer service, but clinical healthcare delivery is a different matter.
“There is a significant amount of tension and debate around the use of AI specifically in clinical healthcare delivery, because it is simply not reliable enough,” Wilson says.
She notes areas where AI excels, like visual identification of skin cancers from scans, sometimes catching more than human reviewers. But most people would not feel comfortable with a computer driving their diagnosis, and even less comfortable when AI is declining access to health services.
“That frontier has not been crossed,” Wilson says. She believes regulatory safeguards requiring human review at certain clinical decision points will be necessary before AI can move deeper into healthcare delivery.
There’s also the cost factor that most people don’t want to acknowledge. Healthcare organizations are enormous, and the computing cost of integrating AI tools has to be borne by someone.
“Everyone argues that healthcare is too expensive while simultaneously expecting those healthcare systems to absorb the cost of that compute and somehow not pass it along,” Wilson says. “These organizations have to pay for that utilization, and there are significant legal compliance requirements that have to be met as well.”
Which brings the conversation back to Wilson’s “unpopular answer” about what needs fixing in American employee benefits: individual engagement with health and the healthcare system.
The mathematical equation is straightforward. Price equals cost multiplied by utilization. Wilson argues that even if you correct all other factors, make everything nonprofit, remove every layer of profit, costs will keep escalating if utilization continues rising.
“We are not a healthy group of people, and I won’t get into all of the reasons for that, because that could be an entirely separate conversation,” Wilson says. “But our utilization of healthcare is continuing to escalate at a rate we’ve never seen before, which means the price is going to continue to escalate.”
She returns to GLP-1s as an example. Many argue that GLP-1s for obesity should be mandated covered benefits because obesity is a serious health condition with real consequences. The core debate is whether medication is medically necessary to resolve obesity, the reason it’s not federally mandated is because it’s not universally considered so.
But from a pure claims perspective, the numbers are stark.
“Metformin costs roughly five cents per pill. Ozempic runs approximately $1,000 a month,” Wilson says. “If one person moves from metformin to Ozempic, they’ve escalated the cost of their own treatment nearly a thousandfold. Multiply that across millions of members doing the same thing, and it materially inflates overall plan spend.”
Wilson acknowledges the sensitivity of this framing, that it intersects with complex societal, economic, and equity considerations, but she maintains that utilization is putting financial and accessibility pressure on systems in ways that can’t be ignored.
“Even if you drive everything to the lowest possible cost on one side of the equation, if you don’t address utilization on the other side, costs are going to keep escalating,” she says. “We really have to think about our overall societal utilization of healthcare as one of the primary contributors to why things are so expensive, and there are many approaches to addressing that side of the equation.”
Outside the complexities of pharmacy benefit management and regulatory navigation, Wilson’s life centers on family, the outdoors, and giving back. Two daughters, both young adults, fill much of her personal world, alongside a love of travel.
Reading feeds what she describes as a lifelong learning orientation, but it’s her relationship with the natural world that feels most telling.
“We’ve become little mole people in our cubes with artificial lights,” Wilson says. “I love being outdoors, even if it’s just walking and listening to birds.”
Wilson sits on the board of a nonprofit that supports smaller nonprofits in the community, taking part in events and opportunities as they come her way. “It’s important to make sure we’re giving back to everyone who needs that support and that help,” Wilson says.
For someone who has spent a career making sense of systems built to resist simplicity, Wilson’s antidote is refreshingly straightforward: fresh air, good company, and the quiet clarity that comes from walking among trees.
