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Hello, everyone. This is Jacob Emerson with the
Becker's Pay Your Issues podcast. Thrilled today to
be joined by Jack Hooper, who is the
CEO and cofounder of Take Command. Jack, thanks
so much for taking the time to be
with me on the podcast today.
Jacob, thank you so much for for having
me on.
Excited to talk with you today.
Likewise, Jack. Appreciate you taking the time to
chat with us. Before we get started, can
you first tell the audience a little bit
about yourself, your background in terms of your
career, anything involving health care, and then give
us an overview of your your current role
at Take Command and exactly what you all
do.
Sure.
So I'm I'm Jack Hooper. I'm the CEO
and founder of Take Command.
So Take Command, we are a software platform
that helps employers
administer the new individual coverage HRA or ICRA.
You might ask, alright. How does one get
into being a, ICRA software
administrator?
For me, my my career actually started not
in health care.
I,
I joke. I I used to work for
the federal government.
I was in intelligence and worked for the
FBI.
But now I say, you know, I'm I'm
even cooler. I work in health insurance now.
So
grateful for that background, but but really what
moved me into health care was was a
personal experience.
I have,
two twin boys that are turning 13 next
month.
So
that's kinda how I mark my milestones.
And as much of a blessing as they've
been, they were an enormous surprise for for
me and my wife. We had just,
left our jobs and families in Texas and
moved to Philadelphia for graduate school
and live living in a nice efficiency apartment
and found out we were pregnant with twins.
And, you can imagine the the shock and
surprise and,
really my personal journey of trying to figure
out, okay, how much do twins cost?
How much in student loans do I need
to take out,
to pay for these twins
is, what got me into health care. So,
Take Command was initially
an early player in in kind of the
ACA
advising,
movement of helping people,
pick and choose a health plan in the
ACA.
We stepped into the predecessor to ICRA,
the QSC HRA,
and started working with small employers,
and then actually had a chance to,
work with,
regulators,
during the first Trump administration to help create
some of the ICRA rules after after broader
health care reform had failed. So,
excited to, you know, it's kinda evolution going
from individual to small business to now with
ICRA
working more and more with,
large employers.
Sure. Quite an evolution of a career you've
had then, it sounds like, Jack, from from
federal government,
intelligence to
health insurance. Day it all makes sense. You
know, maybe there's a bigger plan out there,
but I'm super grateful. Yeah. Sure. Well, so
it's clearly it's a personal journey for you
as well as much as it is professional
in terms of the background of Take Command.
And, you know, you mentioned,
health insurance. It kinda sounded like or at
least what I've heard from leaders in the
industry before, when they talk to people who
aren't in this industry, that it it almost
seems like it would be very dry. But
I think you and I both know it
is it is anything but that. And,
and it's also going through a a lot
of change right now. It always has been.
But right now, as as you know, given
given the company that you help start and
oversee, it's it's a it's an incredible time
for for how this industry and how health
benefits are changing. And
that's that's what I wanted to get us
started about talking today.
An interesting
move out of West Virginia.
There's a county there that recently became one
of the first public entities
to drop the traditional group coverage that everybody
knows in favor of an ICRA through Take
Command.
So maybe for our audience who isn't familiar,
first, Jack, just give us a quick
overview what is ICRA, and then what's kind
of the what's kind of the significance here
of seeing a public entity,
go go in this direction?
Yeah. Great question.
You know, ICRA is a term
you know, it's it's, six years old now,
so it became a thing in in January
2020.
It stands for the individual coverage health reimbursement
arrangement or individual coverage HRA.
I think a lot of health executives, you
know, early on
kind of mistakenly
threw it into the HRA, FSA, HSA category
of, like, oh, okay. Here's another thing or
or another twist.
But but, fundamentally, although it shares the the
three letter acronym with with, HRA,
it really is a fundamentally
new way for employers to think about,
insurance benefits. So it, you know, I know
many of your listeners have been around for
a while, and this this idea of defined
contribution,
always seems to have, fits and starts in
our industry.
Well, ICRA actually now provides the the rules
and regulations,
for defined contribution to be a real thing
in health care. You know, so what that
looks like now is employers,
small, medium, large,
instead of purchasing a traditional group health plan
for for their employees,
now they can offer a defined contribution. So
kind of this four zero one k style.
There's a lot of flexibility with, hey. I
wanna give maybe $300
a month to my part time employees and
600 to my full time or different amounts
based on location,
or other approved employee classes.
It creates this really flexible
opportunities for for employers. It solves a lot
of the problems that,
you know, group health plans have dealt with
in terms of adverse selection or or not
being able to anything more about remote work
and being able to cover people coast to
coast. But it creates this really cool opportunity
for, individual employees now where, okay, they can
go,
purchase a plan in their local market.
Administrators like Take Command and and others have
gotten good at helping advise employees on, hey.
You should pick this plan because it's got
your doctor in it, or this one's gonna
cover your prescriptions the best.
And it creates this
real real kind of flexible,
layer of coverage at at two different levels,
at the employer,
and then at the the employee level.
And the the other great thing about it,
you know, we're super excited to see,
Monongahela
County in in West Virginia,
you know, really be the first
I know some other, like, municipalities have explored
ICRA, but this was a a big public
win for ICRA.
And, you know, they Mongolia faces the the
same challenges that a lot of employers do
of of, hey. We've got rising,
premiums.
In this case, we've got a fixed
tax base or tip or fixed revenue base,
and absorbing,
you know, these twenty, thirty, 40%
increases,
actually gets really hard. And,
you know, so ICRA, because it's a fine
contribution,
it it does provide more cost control to
the employers.
There actually was a an interesting,
their meeting minutes from from their council meeting,
came out yesterday, and there's an item in
it in in the commissioner report.
Let me find it here real quick.
Talking about saving $700,000,
this last year by shifting to ICRA,
and the the cost that their employees were
paying, their premiums,
dropped between about 7%.
So a huge win just by being able
to to control the cost
and and kinda reset the the insurance game.
And it's really interesting. Those those, figures you
you stated there, Jack, in terms of some
of the savings this county will see. And
and I wonder, you know, you said there's
other government entities that have been interested in
ICRA, but this was really one of the
more the the first or the more most
public,
situation that we've seen. So are you seeing
more interest from from government employers?
And could we see you know, I think
fair to say, this is a pretty small
county in a in a smaller state. So
where do we are you gonna see at
some point entire states or or larger,
counties
look into something like this?
You know, I think so. And and I
think,
so so, yes, it's still early days in
ICRA. As mentioned, it's it's six years old,
which and and our,
in our industry, it's it's, you know, the
first inning,
of of a longer game.
But but I think, you know, for for
health plan executives
thinking about how this could evolve. Right? You
know, you've got your,
kinda early mover, early adopters right now.
Now this county,
you know, they,
working with their team,
they were really forward leaning.
They were actively looking for solutions,
and,
ICRO was a great fit, and and now
they're gonna recognize those savings.
You know? And it's it's stories and case
studies like that that kinda move you from
the early adopter phase, you know, into the
more kinda, you know, medium adopter or, a
little bit more mainstream. So I I don't
think it's gonna happen overnight,
but I do think,
you know, steady over time,
ICRO is being is gonna become more and
more mainstream and and commonplace.
And and as a health plan executive,
you know, really thinking about, alright, what is
our ICRO strategy? How do we,
play offense,
if we've got opportunities to that? Or how
do we play defense?
I you know, ICRA, it's it's sub 1%
right now, but if you're not thinking about
it, I think you're you're gonna be a
little bit behind in the next few years
Sure. Or getting caught up in the heart.
Yeah. No. It makes a lot of sense.
And I think just given some of the
group
rates we've seen this year alone compared to
some of those savings you you mentioned, Jack,
I think for a lot of entities, a
lot of employers, it's gonna be hard to
ignore,
moving forward. But I also wanted to talk
wanted to talk about some of the bigger
context
here around ICRA and, of course, the ACA,
and everything that's been going on at the
federal level. Mhmm. With the expiration of the
the enhanced subsidies last year,
no real congressional solution in sight, even if
that is in the form of going down
the HSA path, which we've seen.
Some Republicans really been pushing recently. So preliminary
enrollment data for the ACA, and I know
enrollment just ended yesterday, so we don't have
the final numbers. But it has declined around
the country. Some states, a lot more than
others.
But it looks like as of the start
of this month in January, about three and
a half percent decline around the country. So
I wonder overall how you're thinking about this
as you look through this data,
and as as you see, you know, around
the country, different state marketplaces.
How is this instability affecting employer interest in
ECHO right now? Does it change the value
proposition for workers?
How are you thinking about all this?
It's a good good question, Jacob.
And, you know, we did see a lot
of employers
this year were,
exploring ICRA.
I'd say they got close to the finish
line,
but, you know, some of the political uncertainty
or market uncertainty is like, well, let's wait
one more year. Let's let's kinda see how
things shake out. So,
you know, we we we've all learned in
this industry not not to bet on Congress,
and, you know,
health care reform gets recast as insurance reform,
over and over again.
I I I do think, you know, what's
encouraging, though, is is the long term,
and seeing in in a strange way. I
I I think, you know, we're all hoping
for some reforms or for,
the subsidies to be to come back or
at least tapered down,
over a period. You know, the the sudden
shocks to the system are are what kinda
hurt or or can be be frustrating.
But we are encouraged, though, and now we're
hearing Republicans talk about funding CSR payments,
which,
you know, would be great because that gets
money where it's it needs to be for
lower income Americans and helps bring the you
know, removes the silver loading problem
and helps bring premiums down for everyone else.
You know, ICRA is interesting because it
it doesn't rely on premium credits. Most ICRA
recipients,
because they're getting an ICRA allowance, they're not
eligible for tax credits. So they're that small
percentage of the market that's gonna pay full
freight for for the premium.
And so anything like CSR payments or,
other reforms that can bring down that top
line number are are desirable,
for ICRA.
I I was encouraged, though,
again, as you mentioned, still early days with
getting numbers in, and and there is a
decline.
A big fear I had was, oh, is
this gonna be the,
kinda unwinding
or,
you know, really damaging to the ACA marketplace.
I have a feeling that 3% will drop
a little bit further as as people,
maybe they don't effectuate their policies fully in
in January. But we're but we're past the,
oh my gosh, the ACA is
falling twenty, thirty percent, and we're gonna see
big pullbacks and and kinda
death spiral start,
activity like we saw,
you know, a couple years ago in in
the individual market.
It does feel like it's stabilized.
And,
the encouraging thing talking to some insurance carriers,
okay. While while individual enrollment may be pulling
back,
is ICRA an alternative,
for them to replace some of those losses?
So that's where I talk about, you know,
executives needing that kind of thinking and and
strategy of, hey. How do we lean in
here? And if we're if we're a big
ACA,
carrier and we're gonna lose some enrollments,
let's go make it up in the small,
medium, large business segment with ICRA, to replace
those individual enrollments.
Mhmm. And that's an interesting point. I think
definitely,
is would is catching the ear of a
lot of our listeners,
hearing hearing from you right now, Jack. I
also you know, to your point, three and
a half percent seems to be the worst
number in terms of an enrollment drop, and
it'll probably come down from there, which really
goes in the face of a lot of
some of the projections we were seeing of
that it was, you know, doomsday for the
ACA to your point. So I think that's
also, you know, at least on our end,
worth some follow-up coverage of
where did these projections go wrong.
That's a that's another story.
But like like you've mentioned, it it's early
days still for ICRA, and it's only been
around for six years now.
That all being said, adoption has grown a
thousand percent since 2020 around the country.
I I know the data can be difficult
to to collect. Small denominators
for that growth, but, yeah, it's, it's it's
picking up. And and the the highest end
I've seen in terms of, enrollment is is,
upwards towards a million people enrolled
around the country in these types of arrangements.
And that's on the upper end of projections.
It it, you know, it I've seen in
half, in terms of on the lower end.
But I think overall,
what do you think it's gonna take at
this point moving forward to to move this
from a niche product to to really a
mainstream option that ensures the traditional insurers are
are all in on?
Good question.
Yeah. I think, you know, the projections and
data are are hard to get here. It's
it's getting better. There's some, entities like the
HRA Council.
Kaiser Family Foundation put it on their survey
this year, so we'll start to get a
lot more data.
I I think it's probably in the 400,000
to 600,000,
enrolled range. So it's very small in terms
of the overall market.
You know, but when you look at the
ACA, it was at 24,000,000.
Now it's gonna be, let's say, it shakes
out at 20 to 21,000,000.
You know, what's gonna grow it to 25,
thirty, fifty million is is going going to
be ICRA.
And I think what is gonna,
you know, move that forward,
as the ACA shows more resiliency,
as health plans get better,
you start to see these positive snowball effects.
And and one of the things I like
to talk about is who is the ACA
designed for, and then who is it working
with for ICRA?
So most of the policies, you know, rightly
so, are designed for
subsidized individuals that are are truly independent.
So it's all about narrow networks and and
thin formularies
to try to get that low premium, $0
premium plan and and show up at the
top of the state marketplace.
What's been fascinating with ICRA
is it's attracting a new type of buyer
to the individual market. These are medium and
large employers
employees at at employers.
They want HSAs.
They want,
broader networks. They're less price sensitive. Like I
said, they're not getting a tax credit or
subsidy.
And
what's been interesting, Jacob, is starting to talk
to some insurance carriers that are looking at
this opportunity and saying,
Hey. I can design an off exchange
plan.
Still ACA qualified. Right? But we're not gonna
sell it through the exchange, which means we
don't have to pay exchange fees. We don't
have to do the silver loading thing, and
we can design it, you know, with with,
features that,
these employees are interested in. And and I
share that because I think it creates a
positive snowball where, okay, if the ICRA market
is at, you know, 400 to 600,000
right now,
and we see counties like Mongolia
who are having to move to ICRA because
of cost.
Okay. Well, now there's more in the market.
We see the ACA market stabilize.
We see plans get introduced for this audience
that attracts the next level of county, right,
or the next employer that,
says, well, hey. You know, we don't have
to save as much. It's worth it, or
these options are better or as good as.
And I think you start to see that
that positive snowball effect.
One one ancillary we've studied closely, Jacob, is,
the transition in corporate America from
primarily pension plans,
in the seventies and eighties
to four zero one k style,
plans
in the late eighties and and in the
into the nineties and and, of course, where
we are today.
And it wasn't a sudden
shift. It wasn't like every year or one
year, everyone moved, but it was very,
steady and meticulous. And over a twenty year
period, right, you
see pension plans really start to fade,
and you see four zero one k really
start to to become,
you know,
early adopters and then mainstream, and then it
becomes the primary vehicle for a lot of
employers. I I think we'll see similar movement
with ICRA.
And that's a really good point, Jack. And
and I think even if you were talking
about,
you just talk about pensions to four zero
one k's. If we're talking about, you know,
a comparable of traditional health insurance to ICRA,
you know, that this is something that's been
in place since you could say the forties.
You know, it's gonna take time, to to
un unroll this kind of system.
And and something you'd said earlier in terms
of the traditional insurers
because we're we're hearing that too that it
I think for a while we were hearing
that they were worried it was gonna cannibalize
some of their product lines. But now to
your point, it's a lot of them are
looking at this as as an opportunity,
to pick up more business or or investing
in some of these ICRA administration companies directly,
is what we're what we're certainly seeing.
Yeah. One one stat we love to throw
out, and it's true. We've
validated the HRA council and and with other
ICRA administrators, but,
85 to 90%
of small employers
under 50,
are using ICRA to offer coverage for the
first time.
So we hear a lot of you know,
there's concern about cannibalization.
And, yes, in the in the upper market,
you know, if you're a group carrier and,
it gets busted up and it goes to
ICRA, you you want an individual plan. They
are ready to catch as many lives and
members as you can.
But on the small market, there is an
enormous opportunity,
to get new lives, new people covered,
that have never had coverage before. So that's
that's something that's been really exciting. Yeah. Definitely.
Entirely untapped market. It's it's really interesting to
think about. Well, Jack, you've got the ears
of a lot of those
traditional health plan leaders,
from all over the country right now.
So what else are we missing? Any final
thoughts you wanna share with them, final bits
of advice as we as we look into
this new year?
New year, you know, obviously, we're
not not used to uncertainty,
in in the space.
But, I would really encourage,
executives to to look at ICRA and think
about the strategy there. And,
it's picking up steam despite,
you know,
uncertainty in the ACA, and and, ultimately, I
think it's gonna be a huge component and
and proponent of the of the individual market.
And we're starting to see more and more
stories like this county in West Virginia,
have a huge success,
in moving
moving to the to ICR arrangement.
Now the county is happy and employees are
happy. So that's that's something that I think
you know, and it's it's not just cost
arbitrage or or something like that.
It's it it really is.
Hey. There's there's a way that this can
be a better model.
So I I would encourage,
executives to think about this, you know, reach
out, to us at at Take Command.
We have a whole,
strategy primer on on ICRA. We're happy to
share, and can look at trends in your
local market.
There's resources from the HRA council,
and others as well. And and,
you know, it's it's very small now, but
but I think we're gonna see,
steady and and significant growth. And and and
I truly,
to be a little bit provocative,
I don't know if it's three years, five
years, ten years, but but we will look
back
and say, oh my gosh. What happened to
group insurance? It's all gone away or it's
all changed over. And that sounds crazy.
But, again, if I was talking to a
pension exec,
in the mid eighties, they would have said,
oh, no way.
But but look where they are now. And
we're seeing the pull through demand from employers,
and I think that's what's gonna really start
getting,
the attention of,
health plan executives,
brokers,
and consultants.
You know, employers look at this and say,
heck, yeah. Why why wouldn't I do this?
And, that should be either a red flag
or a giant
beacon of opportunity if if you're a health
plan executive.
It's fun to think about exciting stuff on
the horizon for the industry. So, Jack, I
I wanna thank you for taking the time
to chat with us about what you're seeing
recently across the country and for sharing your
insights with our listeners. We really appreciate it.
Absolutely. Hey. Thank you, Jacob, and and,
thank you for having us on. Real pleasure
and real honor. Absolutely. And to our listeners,
if you'd like to listen to more podcasts
from Becker's Healthcare, you can visit beckershospitalreview.com.