When Karl Quist, a resident of Charlottesville, Virginia, looks at the rate increases in his unsubsidized, individual-market Affordable Care Act (ACA) health care insurance premiums in November 2017, he realizes that they have nearly tripled from the year before and that he will have to spend over $35,000 during the year in premiums for coverage that will entitle him to a benefit only after he has spent another $14,400 in deductible payments. Astonished, Quist starts asking questions. He connects with others experiencing the same situation and reaches out for meetings with the Virginia Commissioner of Insurance and Board of Insurance to understand and explore possible solutions. This case covers the basic history of the ACA; explains how pricing is set for both ACA and non-ACA policies; and discusses risk pools, medical loss ratios, area rate factors, allowable adjustments, and self-insured employer plans. It provides a deep dive into the continued rise in cost of health care premiums and asks, "Who is to blame?" This case is suitable for graduate or undergraduate business classes with a focus on the health care industry, leading health care organizations, ethics, government and public policy, or industry regulation.