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Highlights of this episode include:

• How the reduction in ACA enrollment numbers are affecting out-of-pocket payments
• How should providers prepare for this change in coverage
• Long-term projections

Kelly Wisness: Hi, this is Kelly Wisness. Welcome back to the award-winning Hospital Finance Podcast.  We’re pleased to welcome Tom Furr. Tom is the CEO and founder of PatientPay, the leading patient payments partner for acute, ambulatory, and specialty care organizations. Prior to founding Patient Pay, Tom was the CSO and COO and board member at MobileSmith Health. He was also a co-founder and president of Kinetics Inc., an early online commerce provider for small businesses with partners such as Wells Fargo, First Union, and Netscape. In this episode, we’re discussing the shift in ACA enrollment and how it’s driving more high-deductible health plans. Welcome, and thank you for joining us, Tom.

Tom Furr: Hey, thanks for having me, Kelly.

Kelly: All right, well, let’s go ahead and jump in today. So how is the reduction in ACA enrollment numbers affecting out-of-pocket payments for providers?

Tom: Yeah, obviously, the Affordable Care Act was in the media a lot back in December. And so, it kind of got me thinking of, well, if these people leave the ACA, does that mean they’ll be uninsured, or do they move back to the employer insurance? And so, I started looking at the data out there and it’s quite interesting. It’s obviously, as of, I think, a week or so ago– and these are all numbers from Google Gemini. So, if they’ve changed, blame it on Google. But there was about 1.4 million people that had– or 1.2, 1.4 million that had left the ACA. And the ACA has kind of grouped within the private insurance market. And so, the private insurance market had been growing from ‘24 to ‘25. It was up about 1.4 million folks that were subscribing to insurance and are paying for insurance. And so, the question is, if they’re uninsured, there’s a different way to approach it if you’re a hospital or you’re an ambulatory group or what have you. If it’s insurance, what is that insurance going to look like? And so, what the numbers, the stats are looking at right now is, at least according to Google Gemini, so don’t blame me, the folks that are dropping off of the affordable moving over back to business insurance. Now, not all of them, obviously, but a vast majority of them. So, then the question is, okay, if all of these people are moving over to back to their employer-sponsored insurance plans, and are they all jumping into a fully high-end insurance plan? Is it a high-deductible plan? And because dealing with that versus uninsured, now you got to deal with claims and adjudication, and then you can only start billing at that point, or trying to do estimations on the front end of any services that are rendered.

And it was the numbers…I found them very interesting, at least on the high-deductible plans that are out there. And in 2024, there was give or take 27 to 29% of covered lives were using a high-deductible plan. That number grew to 33% in 2025. So, it was up, call it, 4 or 5%. And the estimation is now with more people moving over to their employer-sponsored insurance, that the companies now are having to find a way to help control costs in healthcare. And right now, it’s estimated it’s going to grow at least 20% in 2026. So, you could have upwards of 40% of people in employer-sponsored health plans now using high-deductible plans. And the other interesting stat was that 59% of employers out there are trying to find ways to control costs, unfortunately. And this is one of the ways to do it. So, it has been kind of an eye-opening experience because PatientPay obviously helps medical groups, hospitals, other folks in healthcare collect more dollars. And if you’re doing it on an uninsured patient, you want to catch them before they come in, you want to offer discounts, you want to incent them to do it. But if they’re moving to high-deductible plans, there’s a different strategy more on the back end, some on the front end with estimation. So, we’ve been digging into the numbers, and it’s been, to be honest, really quite eye-opening compared to the narrative that was kind of given back in December of last year on the potential that could happen with the shift in the Affordable Care Act. A lot of numbers, so I’m sorry to bore you with all the stats and everything.

Kelly: No, no, I mean, those are great numbers. I mean, it is very eye-opening. I have a high-deductible plan, so I can totally understand what you’re saying. But how should providers prepare for this change in coverage?

Tom: Well, that’s the next thing is, as we know, deductibles are becoming more and more a larger part of the dollars that are paid to providers out there. And the individuals now as a standalone, the largest payer into the system of healthcare, assuming you look at individual versus UnitedHealthcare versus Blue Cross and so forth and so on. So, there are lots of areas that need to be addressed in healthcare that, to be honest with you, haven’t been because they didn’t need to, but it’s continuing to become a material part of healthcare. And there’s a couple things that are necessary when it comes to the patient. And one, front and center is clinical care, and to have the best clinical care is priority number one. But priority number two is having a good experience with this portion of it. And for younger folks out there, you see that they are very interested in being able to pay things easily, understand bills, all the different components of what they live in outside of healthcare, right? They are able to go to Shopify to buy stuff. They’re able to do Instagram and buy stuff. I mean, it’s just a part of their day in life that allows them to, if they want to buy something, they can buy it. They can buy it easily. They don’t have to get checks out or get paper statements in the mail. And so, it’s important that medical groups and hospitals allow for patients, one, to understand going in with their eyes wide open on sort of what’s going to be expected of them. It’s kind of like when you take your car in to get fixed. You don’t know exactly what it’s going to be, but at least you have an idea of what it’s going to look like.

And then have an easy way for patients to pay these bills that can be through payment plans, electronically, all the different areas that help them to handle, quite frankly, some big bills. And it’s not that people don’t want to pay, not everyone, of course, but most people want to pay their healthcare bills. There are challenges when it comes to understanding those bills. There are challenges when it comes to paying those bills. There are all kinds of challenges. So, to make it as frictionless as possible for them to understand the bill and to make it as frictionless as possible for them to pay the bill in whatever manner they have. And as you know, Kelly, if you have a high-deductible plan, you most likely have an HSA account with it, hopefully, because it’s tax-free. And you also know that you have limited dollars that are put onto that by hopefully you and your company. So even though they want to pay $1,000 bill, they might only have $200 a month on that card that they can pay towards that. So, they might need a six-month payment plan to accommodate that. And so, to be able to help the patient, one, understand the bill. And one of the things that one of our groups uses, they allow us to integrate the EOB into the patient bill. So now you’re looking at your insurance EOB, you’re looking at your bill, you go, “Okay, these match up, check.” I understand I owe it. Number two, I have an HSA card. Do I even know how much is on this HSA card? So, to give them the ability to understand the total dollars on that card is important. And then three, to give them the ability to pay it based on the limited dollars that are put onto that card each month.

All of these things sound simple, but in healthcare today, it’s pretty challenging. And to be honest with you, I have the HSA card. I have a high-deductible plan. And inevitably, my wife will call me and say, “Can I use this card? Because I don’t want it to, quote-unquote, ‘bounce’?” It’s just you don’t have enough money on it. Right. So I have to log in, look it up. Then I call her back and I say, “Yeah, it’s only a $500 bill. We have it in there.” But if it’s a much larger bill than that, we might not. So, it’s a complex world out there in healthcare and to try and make it as easy to understand and easy to pay is kind of, we feel, mission critical.

Kelly: Completely agree. And I love what you said about making it as frictionless as possible. I can totally support that. So, what are the long-term projections for patients signing up for these high-deductible health plans?

Tom: Yeah, the assumption is that they could be at 50% of the total market within the next three years or so, at least from what I’m seeing. And the expectation is it’ll continue to grow from there. So, it’s a material part of the medical group’s dollars that they collect. And as you know, if you’re a primary care group, you’re now having to collect these dollars because the patient potentially hasn’t hit their deductible yet earlier in the year. And later in the year, you don’t have as much challenging in some instances. But it’s definitely an area that is growing and will continue to be challenging based on the complexities of healthcare. But there are ways to simplify it.

Kelly: Great. Well, having it simplified is always a good thing. Well, thank you, Tom, for sharing your insights with us on the shift in ACA enrollment and how it’s driving more high-deductible health plans. You know, if a listener wants to learn more or contact you to discuss this topic further, how best can they do that?

Tom: Yeah, so our website is https://www.patientpay.com/, P-A-T-I-E-N-T, P-A-Y dot com. My email is tf@patientpay.com. And then our telephone numbers on our website if you’d like to call, but I’d be happy to talk more and learn more about this from others out there.

Kelly: Awesome. Well, thank you so much for joining us, and thank you all for joining us for this episode of The Hospital Finance Podcast. Until next time…

[music] This concludes today’s episode of The Hospital Finance Podcast. For show notes and additional resources to help you protect and enhance revenue at your hospital, visit besler.holdings/podcasts. The Hospital Finance Podcast is a production of Besler Holdings.

If you have a topic that you’d like us to discuss on The Hospital Finance Podcast or if you’d like to be a guest, drop us a line at update@besler.com.

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