Health insurance companies are racking up big profits during the pandemic, sometimes two to three times higher than a year ago. That’s largely because so many customers are putting off their usual care.

Elective surgeries, office visits and even trips to the emergency room have dropped sharply, which means fewer claims on insurance plans.

Four insurers — UnitedHealthcare, Anthem, CVS Health and Humana — together reported almost $10 billion in profit growth for the second quarter. Collectively, their operating income rose 152%.

Who shares in the windfall? That won’t be clear for a while because the costs of COVID-19 could still soar and much of the deferred treatment of recent months may happen later.

Here’s one thing to count on: The cost of health insurance is expected to rise next year — over 5%, according to a survey of large employers, and 3% to almost 10% for individual plans, based on Texas rates posted on HealthCare.gov.

“We shouldn’t be confident it will all work out in the end for consumers,” said Doug Heller, an insurance expert for the Consumer Federation of America. “These companies cherish their profits much more than they cherish their customers.”

Some lawmakers in Washington are skeptical, too. This month, Rep. Frank Pallone, D-N.J., and the House committee he chairs launched an investigation into health insurers. They asked for details of coronavirus policies and spending, and cited concerns about “increased barriers to free COVID-19 testing.”

“These developments raise important questions about the extent to which the insurance industry may be profiting off the pandemic,” said the letter to insurance company CEOs.

Insurers have done many things in response to the coronavirus, including waiving deductibles and copays for COVID-19 tests and care. They greatly expanded coverage of telehealth and reached out to vulnerable populations.

Some companies, not all, have pledged premium holidays, discounts and other assistance, such as helping providers suffering from a decline in business.

Anthem, which operates Blue Cross Blue Shield plans in 14 states, said it’s providing $2.5 billion in pandemic assistance. That includes a one-month premium credit to members in select plans.

Blue Cross Blue Shield of Minnesota said it would give $70 million in premium relief and rebates. UnitedHealth pledged $1.5 billion in additional support, including credits toward a portion of premiums and the waiving of cost-sharing for doctor’s visits in Medicare Advantage.

“We’re making significant investments and making sure there’s no reason for anyone to avoid care because of the costs,” said Jamie Dudensing, CEO of the Texas Association of Health Plans.

The main reason to hold back rebates, she said, is to make sure the coverage can handle whatever the pandemic brings.

“There’s still a lot of uncertainty,” Dudensing said. “We have to make sure — for all those employers and consumers — that the premiums are still there to pay for care and hospitalizations.”

Consumers have an added layer of protection. Under the Affordable Care Act, insurers must spend at least 80% of premiums on clinical services (a threshold that rises to 85% for large group plans). Excess profits have to be rebated to policyholders.

For 2018, over $1.3 billion in rebates were shared with 8.9 million people in the U.S., according to the Kaiser Family Foundation. That included almost 681,000 Texans, who got $91.9 million or an average of $135 a person.

For 2019, rebates are projected to double, totaling $2.7 billion across all markets, Kaiser estimates.

Insurers “are the only entities in health care that have profits capped,” Dudensing said. “Not drug companies, not hospitals, not doctors. That means consumers and employers are always protected.”

Ironically, Texas is leading the legal fight to overturn the health care law, which includes the provision on rebates.

In a survey of 122 large employers with over 9 million covered lives, respondents projected that health spending would rise 5.3% in 2021. That tracks recent increases and comes despite the trends during the pandemic.

Companies are worried about three major threats, said Ellen Kelsay, CEO of the Business Group on Health, an advocate for employers. There’s the potential for a new surge of COVID-19 cases in the fall, perhaps with the flu. The costs of caring for chronic diseases related to COVID-19 could be significant. And expenses for other chronic conditions, such as diabetes, could rise for patients who didn’t maintain care.

“There’s a concern that all this could come together,” Kelsay said, adding that companies are investing in other COVID-19 initiatives, too.

Unlike individual health plans, most private coverage in Texas is through employers who are self-insured; they use insurance companies for administrative work but carry the risk.

If health costs soar one year, the companies absorb the expense (or increase employees’ contributions the next year). If costs decline sharply, they accrue a windfall and can use it however they want.

They could lower employees’ share in the future or use the savings to bolster other parts of the business.

“I’ll lay money that employees in D-FW won’t be paying any less next year,” said Marianne Fazen of the Dallas-Fort Worth Business Group on Health. “Many of our big companies are very cash-strapped.”

It’s a striking contrast: Many employers and workers are struggling while the largest health insurers are doubling their profit margins.

“Nobody wants to see COVID-19 profiteering, and the health plans don’t want it, either,” said Dan Mendelson, founder of Avalere Health, a Washington consulting firm. “This discussion is not going away.”

Insurers are partners with the government, teaming up on Medicare and Medicaid. He said the industry was talking with governors about how to return excess profits to states. He also mentioned an insurer making advance payments to an in-network hospital so it could meet certain financial metrics.

Insurers face a real threat of a spike in COVID-19 cases, but they must be forthcoming about costs and expenses.

“We should demand a high level of transparency,” Mendelson said.

Adjust your expectations here. Blue Cross Blue Shield of Texas, the state’s largest insurer, reported a 3% rate increase on HealthCare.gov. In a memo, under “Reason for rate increases,” the company listed seven bullet points.

Each of them was blacked out.