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This is Scott Becker with the Becker Healthcare

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podcast.

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Today is is one of my favorite parts

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of the week. I get to speak to

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Jacob Emerson.

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Jacob covers at Becker Healthcare the payer universe,

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the payer landscape.

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And and one of the things I love

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about talking to our different lead journalist

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and brilliant people like Jacob Emerson is I'm

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hoping that I learn what our audience learns

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what's going on in the payer world, and

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that's the world he covers.

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Jacob, I'm gonna tee it up. I'll ask

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you to take it away. What are the

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couple of things that you're watching closely in

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the payer world currently?

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Sure. It's it's good to talk with you,

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Scott. It's it's been too long since we

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last chatted, but I, I thought today we

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could talk about everything that's been going on

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over these last few weeks to a month

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with the ACA enhanced subsidies. You know, of

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course, it's it's been in the the spotlight

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politically because it's what the shutdown,

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hinged on. And there, of course, has been

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no solution legislatively

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to to what's gonna happen to these subsidies,

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and ultimately to people's premiums as we head

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into next year.

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But our team has really been, over these

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last few weeks, really,

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touching base with leaders all over the country,

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both at health plans and at health systems,

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you know, just to figure out how are

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you preparing for all of this going into

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the next year in terms of, you're gonna

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see they're gonna see a lot of membership

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losses within their individual businesses on the health

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plan side.

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So that makes things worse for the people

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who do stay in the exchanges, and then

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how the health systems are preparing for all

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of this in terms of what this means

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for their payer mixes,

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arise in uncompensated care as people just, don't

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purchase the type of insurance anymore.

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So just a lot of different swirling,

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factors going on here. I thought we could

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dive into really what we're seeing today as

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as, at the November.

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Certainly. And one of the things I found

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fascinating is president Trump seemed to sort of

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wanna find a way to meet this in

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the middle Yeah. And continue some of the

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subsidies for a couple years.

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And and, of course,

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this was met

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maybe with applause on the left and absolute

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hatred on the right, where where it seems

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like almost people on the right are are

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so excited to get rid of these subsidies

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for right or for wrong. There's all kinds

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of thoughts on whether this is these are

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good or bad. I think all of us,

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at least in health care, believe we should

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have coverage for all. Were the subsidies or

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the ACA the right way to get there?

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I don't know. But But I think generally,

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us in health care think we need coverage

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for all, but we also need access and

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supply for all. But but talk to us

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about this fight on the right where president

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Trump got in the front then saying, okay.

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Let's continue this for a bit. And then

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he got flanked by the right wing who

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said, no. No. No. No. We're so thrilled

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to have these out of here. Talk about

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what's going on there. Yeah. I mean, I

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think just from that that last piece, the

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Republicans are in a pretty difficult position right

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now because,

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you know, when you look at who's enrolled

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or or where a lot of the enrollment

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growth in the ACA has come from over

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these last few years, it's in, red states

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where you where in the past, you saw

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really high uninsured rates, still do, of course,

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but, places like Florida, Texas, and a lot

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of the South,

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they led ACA enrollment growth over these last

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few years. And so this directly hurts,

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constituents on the ground for for Republicans, especially

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those in the house.

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And they know this is this is not

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a weighing issue as we head into midterms

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next year. So there's that side of it,

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but then, of course, there's there's side of

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it that it's that it is Obamacare. And,

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I think just if, you know, we look

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at the grand scale of the grand history

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of all of this, they are against that,

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and they don't want

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to continue this this policy or this system,

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as it currently stands. So,

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the Republicans are definitely split right now. I

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think that's why we're seeing so much waffling

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from from the president, from and the White

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House.

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And and then, of course, that's why we're

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seeing some house Republicans have introduced legislation to

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extend the subsidies, especially those that are in

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really close elections next year.

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But then there's the there's the really traditional

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hard line conservatives that do not want any

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kind of extension,

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made to to the Affordable Care Act, moving

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forward. They wanna let it essentially die on

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the vine.

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So I think that's where, you know, the

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Republicans are struggling here. And that's really over

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these last few days, like I said, where

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we've seen the president go is we we

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heard there were reports, very credible reports,

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that the White House wanted to roll out

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this this new policy to extend the subsidies

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the enhanced subsidies for two years,

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introduce some some premiums into into the ACA,

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so that,

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to avoid some of the the fraud issues

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that Republicans,

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have really been flagging these last few years,

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by requiring people to pay a small minimum

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payment,

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and then and then tying in health savings

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accounts. HSAs,

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basically, people who switch to lower premium marketplace

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plans could, direct the difference in premium costs

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into, those tax advantage savings accounts,

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funded with their subsidy dollars. And and that's

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just been really interesting to hear the president,

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I think, tweet about, say out loud these

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these last few weeks is,

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describing the the insurance companies, which, of course,

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really benefit from from the ACA, in that

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business.

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They're calling them money sucking insurers,

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and saying that instead of this money going

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to the insurance companies in the form of

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subsidies, this money should be flowing to consumers,

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I guess, in the form of of, HSA

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deposits and and things like that. So,

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it's interesting where where the president is going

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and taking more of a populist approach where

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neither party is really a fan of of

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the insurance companies right now, but then also

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just the the the rock and a hard

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place that the Republican party is in, when

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it comes to these subsidies because at the

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end of the day, premiums are gonna skyrocket

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without these.

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And, you know, it's gonna have public because

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I can see that. No. No. No. And

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here's a couple of fascinating takes on this,

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and I'm trying to piece this all together

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because

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regardless of the subsidies,

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for those that are not buying the

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health care through the ACA or through these

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exchanges,

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rates are

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surging no matter what. Those seem to be

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going through the roof almost no matter what.

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So you've got that issue. So now we're

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talking about that category of people that are

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getting subsidies,

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and this is an incredibly complicated spot. You

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say rock and hard place. I think that's

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exactly right. The people that are getting subsidies

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need those subsidies.

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At the same time,

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the

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many, many people on the left and right

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think the insurance companies just sort of get

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richer and richer through the subsidies, that it

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really ends up being a benefit that goes

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through the insurance companies.

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But but I guess in some ways, from

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a Washingtonian

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perspective,

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it's too complicated to parse through all this.

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And then president Trump was trying to hit

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this down the middle some way or shape

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or form by saying we're gonna increase the

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amount of income you have to have to

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have eligibility for this or or decrease it.

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So that sort of made it harder to

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be eligible for the subsidies. Now it's just

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sort of seemingly his trying to swash the

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right wing of his party.

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But but it does seem like we're in

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a rock and a hard place because you

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please the individuals get the subsidies, but you

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also please the insurance company. I saw I

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saw yesterday, for example, Oscar Health went up

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20% on the news that there might be

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some kind of deal around this, which is,

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you know, it's

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in Alaska, it might be a smaller insurance

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company, but nobody loves to see the insurance

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companies getting rich. How do you sort of

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parse through some of these issues?

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Yeah. I mean, I think and what you're

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pointing to and what I've heard a lot

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of people in the industry talking about too,

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Scott, is that

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the the to to your point, yes. It's

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either you get this subsidies or you don't.

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You get the enhanced subsidies or you don't

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depending on your your income level,

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or your family's collective income level. But the

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the the greater problem here is that, that

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the the insurance the products being offered on

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these marketplaces

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are just too expensive for most people to

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afford, without the federal government's,

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literally throwing money,

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to to subsidize them. And I think so

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so that's the overarching problem that just isn't

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going away here.

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Even if these things are extended for two

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years,

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that these health insurance plans are too expensive,

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that that people cannot afford them as they

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exist on their own. And that doesn't really

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seem to be a problem that,

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that that the congress is capable of,

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of attacking

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right now without, the the only solution apparently

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being, you know, this this, Band Aid solution

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of of having the enhanced subsidies.

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So it seems as if it's just a

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problem that is not going to go away

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regardless of whether what happens by the end

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of this year or not. But what I

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also think is interesting,

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in terms of what we're seeing,

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how how we're seeing the insurers respond and

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actually tell us directly,

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the largest one, UnitedHealthcare,

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they're not the largest ACA insurer, but they

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are, the largest health insurer in the country,

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because of the employer coverage. But they're they're,

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raising rates 25%

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on their ACA plans across the 30 states.

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They they offer them next year, and expect

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their enrollment in that business to decrease by

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about two thirds. So one one of the

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largest ACA carriers is literally expecting two thirds

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of their enrollment to disappear,

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without these subsidies in place. And that means

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that the pool that then stays,

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it just it's it's gonna be the risk

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pool changes. People either, it's it's a worse

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risk pool. It makes it more expensive for

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the people who are still there. It's just

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a downward spiral,

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as these as these subsidies go away if

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they go away. So it's so that's another,

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I think, rock in the hard place that

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the the entire country is in is these

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subsidies are really are a Band Aid solution

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to the fact that this is just an

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unaffordable product to start with.

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But if they don't exist, then you get

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this downward spiral where the the insurance becomes

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even worse, as as it stands now. So,

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yeah, it's a it's a tough one. And

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I think that's, again, that's why we're really

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not seeing any

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hard solutions emerge,

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because,

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the you know, there's gonna be some,

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hard But but I think your point your

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point is so well taken

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that the subsidy is whoever you handle this

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is a band aid, and and I'll be

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in an important band aid for a lot

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of people,

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but it doesn't solve the ultimate cost or

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supply demand issues that we have in health

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care. So so it's sort of you could

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do these subsidies forever.

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We keep on driving up the cost of

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health care without making it affordable and quite

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frankly, without improving access.

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And and, ultimately, the harder problem of congress

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solving supply and demand here

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or or new ways of dealing with health

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care seems to be a really, really big

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and real challenge. Yeah. But not one that's

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easy to solve or that people really wanna

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put their heads together and try and problem

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solve around. Yeah. Well, and and one thing

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I I think too is interesting about all

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of this, Scott, is that another macro context

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of of all of this is that, you

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know, that we we have a completely different

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economy in terms in workforce nowadays, in terms

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of people are retiring earlier, so many more

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people are are self employed or freelance,

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compared to decades past. And so,

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you to into your earlier point, we need,

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a a coverage option available for people to

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purchase at an affordable price because that is

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how our our modern workforce

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operates.

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But at the same time, like I said,

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you know, this isn't this isn't affordable. And

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so,

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you know, what's what's what's happened in the

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past under the Trump first Trump administration, we

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saw ICRA come out under the ACA where

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instead of that traditional group policy,

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employers could offer that that tax free advantage

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so that instead of going to the insurer,

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purchasing a plan for everybody, they then give

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they they basically reimburse the premiums money for

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each each employee to go to the ACA

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in their state and purchase individual health coverage.

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And and, again, that was set up by

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the Trump administration in 2019.

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And so they're almost sabotaging that in a

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way, their own alternative to the traditional employer

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sponsored insurance model,

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because the the this risk pool on the

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ACA is probably gonna get worse. These premiums

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are gonna get more expensive.

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So there's an alternative out there, ICRA,

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and and, again, set up under the Trump

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administration the first time.

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And it's and that's that alternative is is

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gonna become,

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less appetizing

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if these

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don't continue to exist. So I think that's

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another piece of all of this as well

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is that, you know, we do need that

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option for people in in this modern workforce,

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and and the Trump or the first Trump

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administration,

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provided that. And then now it's, you know,

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it that's also kind of, seen some some

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issues potentially in the future too, all tying

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back to the this subsidy conversation.

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I I think your point there, Jacob, it

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it is really such an important point that

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if traditionally so many people's

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insurance was tied to their employers

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and we're moving so much more to a

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world where people aren't full time w two

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with a specific company and not not quite

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as

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engaged in getting that type of health care

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insurance coverage.

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These other alternatives of buying insurance directly are

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so important

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and so expensive

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and so challenging.

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Jacob, I know we've got a wrap up

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today. I could talk to you for hours

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quite frankly,

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but but this is really interesting and really

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helpful.

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I'll work with Chanel to get this episode

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out very quickly. Again, Jacob Emerson

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with the Becker's Healthcare. Just brilliant, covers the

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payer world. Thank you for joining us today,

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on the Becker's Healthcare podcast.

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Thank you, Scott.