We appreciate the opportunity to clarify a few points in our Commentary.1 As we see it, the critical incentives for 17th-century London's fire insurers are identical to those for today's health care insurers. In both cases, reduced exposure to risk and better control of costs translate into higher profitability. Cherry picking is indeed one means by which insurers might reduce exposure to risk, but the practice is not limited to health care. Fire insurers also have long sought to cherry pick their clients (a practice well-known to those of us living in the hills of California). Those at higher risk are denied coverage outright or required to pay substantially higher premiums.
Diamond GA, Kaul S. The 300-Year-Old Health Care Solution—Reply. Arch Intern Med. 2009;169(19):1806-1818. doi:10.1001/archinternmed.2009.366