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.