Hello, everyone. This is Jacob Emerson with the
Becker's Payer Issues podcast.
Thrilled today to be joined by two special
guests from NCD.
Sam Melamed is the CEO of NCD, and
Brett Voigt is chief strategy officer at the
company. Sam, Brett, thanks so much for taking
the time to be with me on the
podcast today.
Thanks for having us. We're excited.
Awesome. Well, before we dive into everything, we
wanna talk with you about everything that's going
on in Washington affecting health plans.
Can you both tell us a little bit
more about yourselves, your background in health care,
and what it is that you're doing today
at NCD? Brett, I'll come to you first.
Great.
So as you mentioned, my name is Brett
Voigt. I'm chief strategy officer at NCD.
I actually started my career as an investor
where I spent a meaningful amount of time
investing in health care services
and other highly regulated industries.
In 2013,
I saw an interesting dynamic emerging regarding some
changes
in the financial flows and division of responsibilities
between payers and providers,
which which really was some of the early
days of what now today has become
more broadly known as value based care or
accountable care.
And at that point,
I made the decision to chase that intersection
of payer and provider as an operator.
I've spent the last eleven
years operating in high growth risk bearing entities,
including Stops as an early employee at Bright
Health,
where I helped that business grow from $0
in revenue and 20 employees to 4 and
a half billion in in revenue and about
2,000 people,
as well as started my own carrier, Tenure
Health, before joining NCD via acquisition
third quarter of last year.
As chief strategy officer, I partner with Sam
and the rest of our leadership team to
to really define the future for for NCD
and where we're going.
Fantastic. How about you, Sam?
Yeah. So I call myself the chief insurance
nerd here at NCD, and, I started my
career really as a failed insurance agent. I
was trying to sell insurance to feed my
family and just really struggling to succeed.
And, so at that time, I started a
website called insurance forums. That's now the largest
insurance agent,
website in the country. Gets about 80,000 unique
agent visitors a month.
I really got my
education in the insurance ecosystem from managing that,
managing that community.
I also got a job at a trade
association's
insurance program called the ABC Insurance Trust, and
I was there for about fifteen years climbing
through the ranks, eventually took over as CEO
until about four years ago when I moved
over to be the CEO of NCD.
So NCD is a product development and distribution
company. We partner with leading insurers to build
interesting supplemental health products
and then to work with Medicare and ACA
distributors to have them distribute it. So really
no one is in the business of exclusively
selling dental or vision or stand alone supplemental
health coverage,
And so we build products and partner with
distribution
in both of these markets, and that's why
we pay so much attention to the regulatory.
Fantastic. Well, Sam, Brett, like I said, we
really appreciate you both taking the time to
chat with us today. I wanna get started
by talking about regulatory, Sam. There's there's obviously
a lot going on in Washington right now
and certainly a lot that will be affecting
the health plans and the leadership listening in
right now. So
let's level set for a for a moment,
and and can you talk to us a
little bit about some of the key
regulatory shifts within under the ACA,
that health plans should be preparing for right
now from your perspective?
Yeah. Well, the the timing for the question
couldn't be better because the new regulations
just dropped
a couple days ago around the ACA, and
these are the first regulations that the Trump
administration has dropped.
And it was no surprise. Actually, Peter Nelson,
had telegraphed his views pretty clearly in some
white papers he had released, and lo and
behold, the regulations really seem to,
to shape around that.
And I would call it mostly a vibe
shift before you get into any specificity of
what the new regulations are.
The previous administration
seemed to focus on growth of the ACA
at all costs,
that growing this program will instantiate it. It
will lock it in. It's, a public good,
and there's a lot of
philosophical reasons for it. But most of the
regulations
that they put out of the the four
years of the Biden administration were really designed
to shore up or strengthen the ACA marketplaces
in the way that they felt was appropriate.
Whereas
right now, the new regulations that dropped are
really focused on cleanup and integrity.
So, really, a lot of people assumed, and
there was a lot of ink spilled around
how the Trump administration would look to hurt
the market or would look to get rid
of the ACA.
And I think they were pretty clear that
that wasn't their intent,
and you can start to see that play
out now with some of these new regulations
that, yes, we might see growth slow or
more likely some shrinkage,
but their focus is less on,
getting rid of the marketplaces and more around
making them economically viable
and removing a lot of the waste, fraud,
and abuse.
You know, the the big debate in DC
is around the extension of subsidies. That was
the thing that really grew the ACA more
than anything.
And, actually, the new regulations could signal
perhaps that there's some view that the subsidies
might extend because a lot of the new
regulations that dropped,
which would not go into effect until 2026,
which is when the subsidies end, are really
designed around
tweaking elements of those subsidized members.
Fascinating. Okay. So from a bird's eye level,
Sam, you're you're basically saying the Biden administration
really focused on the growth
of the ACA, and now the Trump administration
is focused on integrity
under that program.
And it's there were possibly seen signals of
an extension of the premium tax credits, which
would certainly be very good news for health
plans and hospitals
all over the country.
But, Brett, would love your take here as
well.
Yeah. Of course. And, you know, recognizing that
we at NCD bring the perspective of a
dental provider,
one of the things that we track really
closely with regulation is the interplay
of dental and other supplemental benefits in the
ACA market.
An example of this is is last year,
the Biden administration
enabled states for the first time to include
adult dental
as an essential health benefit benefit for plan
years as early as 2027.
Though a number of complicated
questions remain regarding how this is gonna ultimately
be administered,
such as, you know, what what will a
reference plan look like?
And with the change in administration, for us,
it's gonna be really interesting to see how
the current administration
addresses this proposal
and others like it that are set to
go in effect in future years,
and and to see, you know, will this
interplay of dental and ACA offerings really play
out, or will the administration
change directions there?
Yeah. Absolutely. It's it's interesting to think about.
And, you know, one thing I wanna do,
Brett, is step back for a second for
our audience. I think this would be helpful,
to ask you what the state of ACA
market enrollment is right now, because Sam mentioned
the growth that happened on the previous administration.
Have have you all been seeing any notable
year over year trends up until this point
in terms of who is enrolling in ACA
plans?
Yeah. Great question. And as Sam had mentioned,
you know,
CMS's own communications over the last four years
have consistently put that emphasis on growth.
Right? With the market today now at an
all time high with over
20,000,000
Americans enrolled in the ACA.
The thing that's most notable about growth,
over the last year is that that we've
seen
both states that run their own exchanges
see the greatest level of growth
as well as the fact that states that
typically have voted Republican in presidential elections have
actually seen the strongest growth in in recent
years.
And
it it it's gonna be really interesting to
see how that trend evolves,
going forward from here,
particularly in light of Sam's point about the
shift in focus from growth to stability and
integrity of the ACA market.
We definitely see some early indications
that the Trump administration
is focusing on issues like
risks with auto enrollment. And
while it's hard to be declarative about what
specifically will happen, we certainly have the expectation
that
growth will
likely meaningfully decelerate and and potentially
even see enrollment decline
in the upcoming year. I would add to
that
that we clearly saw that some of the
broker enforcement rules
that were put in place in response to
really the wave of fraud that did come
out of, you know, some of the easy
additions
to the ACA since the premium subsidies were
created,
that a lot of that did shift where
there was less new business being written on
healthcare.gov,
but the total number of enrollees through the
federal exchanges did still grow because of how
easy it was to auto enroll.
And so one of the very interesting
pieces of the new regulatory proposal that was
just put out is the requirement that there
be a de minimis $5
fee for anyone who,
had no cost share previously, but who had
not affirmatively
resigned up to a new plan.
And so I do think plan executives
do have to take a look at
what are the signals in their current book
of business
that some portion, maybe some small portion of
their membership
might not really even realize that they're in
a health plan and therefore, of course, have
no utilization.
And if the $5 fee is gonna kick
a bunch of those people out because
they will either get rid of fraud or
they'll realize they had a plan that they
didn't think they had or maybe they qualify
for Medicaid,
then what does that do to their potential
MLR? And so I think that
there's a lot of focus in the new
proposed regulations
that have a lot of impact around program
integrity
that smart plan
administrators and insurers
right now have a war room thinking about
how do we project our MLR and price
our plans prop properly for 2026.
So, Sam, let me come back to, something
you had mentioned earlier. Peter Nelson being appointed
to lead the Center for Consumer Information and
Insurance Oversight.
As you know, he's an he's an ACA
expert. He has a lot of knowledge about
state innovation waivers, price transparency,
health reimbursement
arrangements.
So so what do you think his appointment
means for for the insurers listening in and
for the consumers and the members that they
serve?
Yeah. You know, I have a huge amount
of respect for Peter Nelson. He's been writing
and thinking about and talking about the ACA
and health care more broadly for a really
long time.
And in many ways, his appointment is really
good news for health insurers because he's been
pretty clear about what he sees as potentially
broken
in the healthcare ecosystem
and in particular in ACA
and what are some of those ways that
it can be,
it can be addressed. And so he's put
out publications
that specifically talk about
why the ACA structure or some of the
regulatory structure has an extra cost to consumers
with even pretty specific calculations
of what each of these new laws, whether
they're preenrollment
SEPs
or allowing states to update and modernize their
essential health benefits
or narrow de minimis variation actuarial values. There's
any number of them where he's very specific
in his analysis of what the premium impact
is gonna be.
So while the regulations that were just released
come out of a playbook that you can
find in his previous writings, I think a
lot of smart insurers are saying, alright. Let
me read everything he's written. Let me listen
to everything he's been recorded as saying. Because,
he has been pretty clear about his perspective
for a while.
I think the other thing that's becoming clear
is to the point I made earlier,
there was a lot of ink spilled when
there was an election
going on, and there was maybe a political
reality to the discussion
that
the Republicans
wanted to scrap the ACA or wanna get
rid of the ACA.
But to Brett's point, some of the growth
in red states that the ACA has seen
and where the population that is being subsidized
right now lies,
and given
the two year cycle for
Congress and the slim majority,
it's
very hard to imagine,
any kind of wholesale change
that's going to really hurt a lot of
those people who are being subsidized right now.
So it's somewhat of a contrarian take, I
think, from the rest of the market. It
does seem like many people think the premium
subsidies will not be extended,
but I would bet actually that the premium
subsidies may be extended,
maybe with some tweaks like,
work requirements.
And
so it does not appear that they're looking
to undermine the ACA
as much as they are looking to,
really focus
on
not being wasteful and not allowing fraud, some
of which has
propagated over the last few years.
No. Your your point is well heard, Sam.
And it's certainly it's an argument we've heard
from insurance executives on earnings calls with investors
talking about the sustainability
of of the ACA
moving forward and and the popularity of of
that program with,
with people in Republican led states.
It even specifically mentioned among Trump supporters specifically,
and and that's certainly been an argument that's
been used when discussing Medicaid cuts or potential
cuts as well. So it's it's an interesting,
it's interesting to hear your perspective on that
in terms of what could happen to the
to the subsidies.
But, Brett, I wanna I wanna I do
wanna switch gears in just a sec, but
I'd also wanna get to the crux of
things, before we move on from the ACA.
Given all these changes that we've talked about
today that have been announced or that could
be on the horizon in this market,
How should
marketplace plans be thinking right now about repositioning
themselves
for long term success over the next few
years?
Yeah. That's a great question. And
when when you think about
those in the market who are ACA focused,
you know, obviously, you have you have carriers,
but you also have,
distributors who have who over the last few
years have largely built their business
serving the ACA markets and in in enrolling
individuals,
in ACA plans.
Our view is that right now is really
the time for those ACA focused distributors
to add resiliency to their businesses through diversification.
You know, now is the time for them
to expand their horizons beyond, you know, just
considering themselves
ACA distributors
and and really thinking about the ways they
can more broadly serve the needs of their
clients
through through the sale of a number of
related ancillary health products that frequently,
you know, complement
ACA plan coverage.
Additionally, by by by diversifying their book of
business, they can also create additional value
for for their clients,
and and deepen their relationship with their their
client base by by solving a greater number
of of needs.
And, you know, obviously, there there's a range
of compelling ancillary health products.
You know, at NCD, we're we're particularly partial
to dental and and vision being some of
the the most notable. But but there there
really is a a broad opportunity for ACA
participants to think about these these these other
products and how how they can bring them
bring them to clients,
in in the months ahead.
Absolutely. Yeah. No. It's great advice,
for for everyone listening in.
I do wanna switch gears here and and
talk about Medicare Advantage because, obviously, it's been
a wild year for that program,
and certainly for for carriers,
in Medicare Advantage.
We've seen enrollment growth slow now that the
the data is out,
slow to,
at least the the the lowest it's been
in decade in a decade.
Plan benefits are shrinking.
Millions of seniors are being left with coverage
gaps, certainly within dental care.
So, Brett, how do you think this shift
within MA is impacting the demand for stand
alone dental,
vision, and hearing plans?
Yeah. That's
that's a great question. And and
it's worth calling out that these reductions,
you know, don't look the same in in
every market.
Right? Sometimes they take the form of the
removal of a benefit
in entirety.
But but even more commonly, particularly for benefits
like dental,
these reductions,
you know, you know, they may be hard
to see, but they really take the form
of the benefits being called out, you know,
whether it's through network changes and reductions,
lower total benefit value,
the removal of certain services, you know,
for example, implants
from included coverage. And and across all these
types of changes, we really view them as
a as a potential opportunity for the stand
alone dental market,
for for NCD and others as well.
And really the reason is
as these benefits are pulled back, we believe
many Medicare Advantage members are gonna reassess their
dental needs,
and and what coverage they need and and
consider adding a stand alone dental plan
to their coverage separate from their Medicare Advantage
coverage.
And
we believe for a significant segment of Medicare
Advantage members with these benefit pullbacks,
there's there's gonna be strong value for them
to pay, you know, a small premium for
that additional standalone dental plan,
rather than having, you know, included but highly
limited dental coverage,
as as their only way to access, you
know, critical dental services.
And and so we've we view that as
a a really intriguing, you know, development on
the horizon for the market. Yeah. Absolutely. So
it sounds like the time is ripe for
the growth of stand alone dental plans.
Anything you'd add there, Sam?
Yeah. I would say it's an open question
whether Medicare Advantage Plans should, in fact, cover
all the supplemental benefits that they have or
not. You know, it certainly wasn't the original
intent, and there are trade offs. There's certainly
a lot of nice things, and they've been
very effective
from a marketing standpoint.
When I think about what policy makers, in
particular,
legislators could think about, one interesting idea we
haven't really seen floated is
that many,
many people who receive their supplemental health benefits
when they're working get to pay for it
with pretax dollars through a section one twenty
five plan or because the company pays for
it. Whereas when you retire, you really can't.
And so if you're going
to have the economics of Medicare Advantage make
it difficult to embed additional supplemental plans,
then perhaps there could be a tax break
for those dollars.
Currently,
it's only dollars you spend in excess of
7.5%
of your modified adjusted gross income that are
tax deductible.
So it effectively costs more for those people
who are not actively in the workforce to
actually ensure some of those needs.
Understood. Understood.
Okay. So we've we've gone through a lot,
talked a lot about the ACA, talked a
lot about Medicare Advantage.
Anything else you both would mention in terms
of the biggest potential regulatory considerations
that
our health plan and hospital system stakeholders
really need to keep an eye on at
the federal level.
Brett, you wanna start us off there?
Sure. Absolutely. Well,
I think the the the most interesting potential
trend is is
not just the regulations are coming, but
as the regulations come will be the the
potential
change in approach that
that,
private market participate
participants take
to competing in the Medicare Advantage and ACA
markets,
While not knowing, you know, all the ways
regulations will change, I I think as they
they come to market, one of the thing
we're
likely to see
is that the general
approach of
more benefits, more supplemental benefits equals a better
strategy actually could could very much change. And
instead, we might see
a number of
ACA
and Medicare Advantage participants intentionally focus more on
core medical benefits
and and really trying to differentiate there rather
than through, you know, a a broad portfolio
of supplemental benefits,
which which has the potential to serve, you
know, the
needs of a segment of consumers who are
looking,
you know, not for for the buffet plan,
but who are looking for the best medical
plan. And then in turn, we'll be looking
for, you know, alternative standalone options,
to cover
their their other health related needs. So that
that's one really interesting trend,
on the horizon that that I will be
looking for.
And, Sam, how about you? What are you
keeping an eye on or any other final
thoughts that you wanna share with our listeners
today?
Yeah. I'm certainly keeping an eye on some
interesting
ideas that would have been more out of
the box,
things like multiyear plans where plans can really
invest
in and make commitments to wellness and to
really bending the cost curve,
knowing that they will receive some of the
benefits of the lower utilization
rather than, you know, than some other insurer
that people move over to.
I think it'll also be interesting to see
whether they take a look at some of
the MLR regulations
that, while well meaning, might effectively
cap margin and therefore drive some of the
consolidation
and reduce some of the incentive from plans
to really drive for better control of health
care costs.
So I think it's an exciting time to
be in health care.
And then the last thing would be the
general zeitgeist in health care is that we
spend too much money on it, and people
are not very happy with it. And so
I think, well, a lot of insurers are
focused on automation and outsourcing and finding ways
to reduce their costs.
Sacrificing around member experience,
does not seem like it's gonna pay dividends.
And so I would certainly be encouraging
this topic for another day, but for, smart
health plans to be very mindful of that.
Fantastic. Well, I think that's a great place
to leave things. Sam, Brett, thank you very
much for taking the time to sit down
with us and for sharing your insights with
our listeners. We really appreciate it. Thanks, Jacob.
Thank you.
And if you'd like to listen to more
podcasts from Becker's Healthcare, you can visit beckershospitalreview.com.