Mark Bertolini of Oscar Health 3-13-25

One of the things is employer-sponsored insurance. They buy it for everybody in their group, which means a larger network, which gives you higher costs because a lot of providers in the system. Secondly, what it does is gives everybody an average benefit. So interestingly enough, last year Americans spent $74 billion to pay for their medical debts even though they had coverage. And one in five people under 39 had problems with their medical coverage and had to borrow money.

Well, number one, the largest pool in America is the individual market with 24 million people, the Affordable Care Act. And in that marketplace, everybody gets the same right regardless of their illness. So there's no underwriting of the individual based on their illness, and they get subsidies if they're under certain levels of income of the federal poverty level in order to help afford that. And so when you look at all of that together, a sick person doesn't get penalized. Healthy people get to buy what they want. 75% of all physicians in America are in the ACA, so I can find my doctor. I can buy a plan design that fits me, where often with a large employer I'm overinsured.

No, if you look at the overall ACA and its rate of increase over the last five years, it's been at or below CPI. And in the 1980s, that was what we called nirvana in healthcare reform. If we could ever get to a point where our healthcare costs rose at the same rate or less than CPI, we had a good program.

Well, Medicaid's not part of the ACA.

Well, how do you fix that? Why the ACA and Medicaid are related obviously. Why do so many people need Medicaid and why do so many states abuse what it's used for? Well, the funding mechanism, the sharing between the states and federal government isn't very efficient. Not only that, but they get twice as much, so they start saying we're using it for this, that, and the other thing, and they're getting reimbursed at twice the rate for these crazy programs that have nothing to do with healthcare. And the networks are not as strong as the networks in the ACA. You don't have that level of participation. And so if we could add more individuals to the current ACA marketplace, 75 million people in small group of middle market employers, 20 million, 21 million gig workers in the economy, if you can put those people into that pool, it gets larger and it gets more stable.

Because there are certain tax subsidies you lose as an employer when you do defined contribution. So part of what we put in that bill was that conversation: let's make it possible. Secondly, there were restrictions back in the beginning because the Obama administration was concerned that if they allowed small businesses to put employees in there, they would put the sick employees in and leave the healthy employees out, and as a result the risk pool would get worse. And that hasn't happened.

So along with the ACA legislation, okay, so that's a fine point. It's not part of the ACA. It's not part of the ACA. But they expanded it, and that's why we're in this right now. And the states that didn't take it, like Texas, eventually took it? No, they didn't take Medicaid, and they've created their own state-based exchanges for the individual business. Georgia now has an exchange, Texas is building an exchange, Indiana. So red states are now saying, I get this. Get everybody into an individual market where they can buy the product they want at a price they can afford, have money left over for employees that come out of defined contribution, so they're not borrowing money to pay their debts.

10% on average for one pregnancy, right? A healthy event, a good event. And it raises it by 10% because what happens is the experience of the group goes up and you have to spread it over 15 people. So if you're talking very small businesses, that's where you really get into issues with some of these things too. So it's a killer.

Well, the good news and the bad news is that we have grace periods, and if the government stops funding the subsidies for individuals, there'll still be time for us to catch up on that. I don't think that will happen. I don't think they're going to. 63% of all the people in the exchange now are from red states because they didn't get Medicaid expansion, right? So when you look at the polling for the Republicans, 80% of voting Republicans want to keep the enhanced subsidies. A family of four making $55,000 can't afford to lose their subsidy in their healthcare coverage. And we cut in half the uninsured in America. We now only have 7% in America that are uninsured.

Nothing. UnitedHealthcare, I'll share a conversation between our medical director and a physician who asked for something for someone who was dying, and we said, why are we doing this?

They wanted to do an additional procedure when the person was clearly not going to make it. And the doctor's response was, when I walk into the room and the family looks at me, they ask me what we can do next, and I feel I need to give them something. Right. None of us are going to make it. Nobody gets out alive. So this idea of having honest conversations about what's appropriate. I will tell you, somebody who's been on the receiving end of some of those conversations with family members, it's so emotionally fraught. And there are cases where people come back. Yes, there are. My son, he came out of hospice. So what we need to do is we need to make hospice for end of life available without condition. Today, when you go into hospice under Medicare, you have to stop getting curative services and you have to admit you're going to die. You have to essentially sign and not try to recover. And so if we could have it where people could go into hospice without having to do those things, and we did that at Aetna, and we saw an increase from 20% of people going to hospice to 80% of people going into hospice. And the letters we got from families about how end of life happened were so compelling. And it was actually cheaper. Nobody was grasping for something at the very end, but you allow them the hope of being able to get it if it should occur. And that means everything. But having to say you give up is a horrible thing. It's a horrible process. So we have a product in front of us, we have a market in front of us that can work for all Americans if we can get the legislation right and the policies right to allow employers to do the work. And it's a marketplace where nobody gets penalized for being sick because the rates are set across the whole market, and Americans can choose what they want.

Yeah, let me offer a few points. Yes. First of all, there are a lot of immigrants in the ACA today, and that's part of what happened this week when they passed legal or illegal, both. So that's part of what they passed on making sure people were legally in the ACA. Number one. Number two, the patterns of people coming from South America and Mexico are fundamentally different, particularly if they've never had healthcare or if they've had healthcare in their countries. When I ran South America for Cigna, the people used to line up around the hospital to get what is called a reimbursal, a ticket, so they could go and get healthcare. So where do they line up here when they come? At the hospital, and they end up in the emergency room, and it's highly costly. So we have to have programs specifically designed, and that's what Oscar is about: call us first and we'll help you get access to the system.

Yes. Were you scared when you went to a 401k?