Over $1.3 trillion is spent on private health insurance, with per-enrollee spending by private insurers growing by 61.6% from 2008 to 2022. The primary reason for this increase in per enrollee spending is a result of the increase in health care prices, with the Consumer Price Index for medical services growing at an average rate of 3.1% per year compared to 2.6% per year for the Consumer Price Index for All Urban Consumers. Prior to 2022, employers and employees had very little access to understand expected health care costs for services and procedures, but that all changed with the Transparency in Coverage Rule and the Consolidated Appropriations Act.

The Transparency in Coverage Rule has five goals that meaningfully impact health care consumers, as listed below:

1. Establish a market-driven health care system
2. Enable comparison shopping
3. Expose real-time pricing information and out-of-pocket liability 
4. Stabilize and reduce the price of health care services
5. Empower, inform, and incentivize action from consumers

The pursuit of these goals upon plan sponsors began July 1st, 2022 when the first phase of the Rule became enforceable with the publication of two machine-readable files (In-Network Negotiated Rates and Out-of-Network Historical Billed Amount). The pursuit continued into 2023 and 2024, when the second and third phases of the Rule required that health care consumers be equipped with a cost-comparison shopping tool for 500 identified items and services (2023) and then all covered items and services (2024).

Concurrently, enforcement of the Consolidated Appropriations Act of 2021 had begun, which placed plan fiduciaries under the microscope regarding how they approached health plan costs as fiduciaries. These two combined efforts led to the expectation that plan fiduciaries may eventually be put into the legal spotlight if they fail to practice their fiduciary duty of "loyalty" and "prudence" in managing health care costs.