Inside the Industry: A Breakdown of the ACA Subsidy Changes for Group & Individual ACA with Mark Mixer
Inside the Industry is a recurring video series hosted by AgencyBloc to take an insider's look at the health, group benefits, and senior insurance industry. Learn more about what's happening right now, what it means for your agency, and how your team can stay ahead of these changes.
Transcript for the Episode
Note: AB denotes Allison Babberl, and MM denotes Mark Mixer.
Allison Babberl: Welcome everyone. We are back for another edition of Inside the Industry and I'm here with another guest, Mark Mixer. Mark, all right, I'm gonna run through all of it. Give me 10 minutes to say all of your titles and names, but you are CEO of HealthOne Alliance, CEO and Founder of HRASimple, and chair emeritus of the HRA Council. Did I miss any of your other, you know, side gigs, side hustles? No.
Mark Mixer: Yeah, that's plenty. I have three, and I have three dogs. How about that?
AB: Three dogs. Well, you know, just keep it all in the threes. Welcome. Thank you so much for joining me today, Mark. Well, I know you and I've been talking a lot there's a lot of noise going on with Washington right now and what is happening with the ACA subsidies and all of that, but I think it really boils down to this, Mark, premiums. Premiums are a problem right now. They are increasing some places, it's double, some places even more. No matter where you are, your premiums are going up and this is hitting people really, really hard. And as you and I were just chatting not long ago, we're coming up on the end of Open Enrollment. We have less than a month, a couple of weeks left. How do people address or how do agents, brokers address these changes in premiums, these skyrocketing premiums to help just bring some peace of mind to their groups and employers?
MM: Well, certainly not easy without exception.
AB: It's a loaded question.
MM: Everything's incremental these days, right? It seems that no matter what you ask, the answer isn't a simple black and white. It's, well, it depends, right? It depends on what your situation is. And I think that still applies. I think agents, particularly in an effort to be efficient in this compressed time window that we have left, you've got to continue to bring people back to the fact that, all I am is a messenger of what is available to you and a guide to help you narrow those choices down. So that at the end of the day, you're making what is the best of horrible choices out there, right? Yes, I'd love a plan that costs half as much or that costs the same as it did back in 2023. But that's not the reality. Today, these are the premiums. And that may be exactly the same way anybody else budgets it for anything. I'd love to always buy premium macaroni and cheese. Kraft Deluxe is my preferred. But if I'm on a tight budget, I may have to go with the Walmart version of it for a little less money this year and just not be as pleased about it. And I think that as much as my wife tries to be frugal, I can always tell the difference, all right? But that's the reality of being an adult, if you will, within a budget, all right? And I think it'd be great if we could have someone solve all of the problems that we face in healthcare. And certainly Congress is gonna, you know, battle those ideas out. But they're not gonna battle that out in the next three weeks, right? In other words, I don't think you're gonna see anything significantly change. So you've gotta help people sort of swallow that bitter pill, initially, and then deal with what is and narrow down what makes the most sense. And that may mean taking on a little bit more risk this year, right? Instead of buying a gold plan, you may have to go to silver. Instead of silver, you may have to go to bronze, right? I don't think the answer, again, is, just put money in an HSA. Well, that's great if you have disposable income, but not everyone does, right? So I think there are variety of ways that, whether it be Congress or whether it be your state, are trying to find alternatives to what is this persistent problem. But it certainly appears like we've reached the ceiling, right? And I do think it might be an existential year next year in terms of healthcare.
AB: I think you said it really well earlier, Mark, when you and I were chatting. It's not just about finding the cost. It's finding the coverage, right? Looking at what do you need? What do your employees need? And what kind of plans actually offer coverage like that? It might not be that traditional insurance is the right path for you any longer. I know where I work, we have looked at different options. We did a level-funded way back in 2017 and it was an experience, right? It was different. All of us had a learning curve with it. Luckily we had a great agent that helped us through that process to help educate us on what does this mean? What do I need to tell my provider? But how does looking at different options and going back to the real substance of what do you need covered, what does that mean to you?
MM: I think it depends if you're dealing with an employer, right, almost all employers that I've experienced over the 40 years I've been doing this, they tend to be very paternalistic, right? They truly care about their employees. I think that gets, I think they swing that pendulum though, oftentimes too far in believing that somehow they're the only ones that can make what is to be the best decision for what that care should look like. And employers are shocked, particularly when they move out of a traditional model and into an ICHRA model, for example, where there's a lot of choice and people are like, well, they'll never be able to figure out how to pick a plan. And it's like, oh, you mean like the 42 million people in America that pick it every year that seem to do okay with it? But employers think differently, right? They think, I need to. Well, just look at the data. The uptake rate for employees picking plans, even though they're offered a plan, is on the decline. Ten years ago, it was 75%. Today, it's 67%. So even though I may think what I'm doing is making a wise choice for my employees, they don't consider it is very well because they can't afford it or it doesn't fit their need, whether it's their budget or their need and so they're just saying I just won't pick anything right well that's not solving what the purpose of providing benefits was to begin with — recruit and retain people right so I think we forgot to ask that question that you that you begged, Allison, what what is it that my people really want? Real quick, Kaiser does a survey every year. They've done this for the last eight years, I think. Kaiser Family Foundation. They ask small employers, small employees of a small firm, would you rather have $2 more an hour or health insurance? 75% to 80% of the people every year for the last eight years have said, I'd rather have $2 more an hour. Something's wrong with that. And it's because we're not creating benefit packages, welfare packages, that actually are perceived as being of more value than they actually cost. And so we end up with this sour taste in our mouth, and we just perceive the benefit as a hassle. And once a benefit becomes a hassle, it's not much of a benefit anymore.
AB: Yeah. I know I have plenty of friends that, you know, are employees. And I know many people in my life, I ask them about their benefits. And they're like, I don't know. I just go to the yearly meeting and I sit there with a glazed over look. And I'm like, really? You don't understand? You don't look into it at all? And I think, you know, coming back to the conversation, Mark, the ACA subsidies, they're in flux, right? There's going to be changes.
MM: Yeah.
AB: Regardless of what gets figured out here in the short term and the long term. We know it's not a long-term plan. We know it's not gonna keep our premiums down. So what can agents do instead? How can they help make these last three weeks the most smooth sailing as possible for their clients and their prospects looking into 2026 and helping them prepare even for 2027?
MM: Well, I think it depends on where they normally fit on the income scale, right? Believe it or not, not everybody, every human being in the individual market is going to get financially bloodied. Certainly, there are those on either bookend that will, but there are those that will actually benefit from it. I think you've got, I'll call them feeble attempts by the federal government where they made bronze catastrophic plans and then premiums for direct to primary care, HSA eligible. Again, that's great if I have disposable income. It's a great financial planning tool. Probably one of the greatest tools out there, but only if I can take advantage of it. Everyone else, I think you have to eliminate the noise, right? If you think you can predict what Congress and the subsidy fairies are going to do in Congress, God bless you, okay? I'm one of only 340 companies in the entire United States. And I don't know what they're gonna do, neither do my 340 other CEO colleagues, all right? But we're gonna have to do just what you are. We have to wait until the rules come down and then we navigate within the rules, right? Because that's what's being presented to us. It's just like any other trial in life. You're not going to get, nobody's going to come pick you up and put you out on the other side. You're going to have to get through it, right? And that means buckling down, being honest about what the options are, and then weighing what makes the most sense from a probability standpoint. I had someone say, I just went to the emergency room. And I go, what are you talking about? Why did you go to the emergency room? Well, I needed an MRI, and they couldn't get me in for six weeks. And I was like, my god, so now we're treating the emergency room like it's an urgent care center, but with better lighting. And it's like. What have we become when that becomes the way that we use health insurance? So I think it's fair to challenge some people's thinking about this. Tailored networks, tighter networks, it's a way to reduce costs. But no, everybody has to have a PPO. Why? For that one doctor that one out of two million people may need to go to Kansas City to see a microsurgeon for, I gotta be able to have that. Well, you're gonna pay for it, right? But you can't have both, you can't complain that it costs too much, and then spend freely. And that's just normal.
AB: And I think looking to the agent, this is, you know, it always sucks being at the precipice of when change is happening. It's right. It's not fun. It's hard when everything's rising. It also feels like everything is collapsing and it probably will get worse before it gets better. But I think this is a real opportunity for agents to look outside of that tradition, that norm.
MM: Yeah, you're a point of the spear.
AB: Ask what other options could I offer my clients? Because I think at the end of the day, and you can correct me if you think I'm wrong, Mark, but I think at the end of the day, if agents aren't offering other options, other paths, whether that is level-funded, QSEHRA, ICHRA, any of those big buzzwords right now, if they are not offering those, I think someone else is gonna be happy to swoop in and show your clients those employers that are stressed about the finances, stressed about what's happening and say, hey, I've got this option. It is a little bit more risk, but it is also potentially financially more suitable. And I think that is a place where agents really need to challenge themselves these next three weeks and going into next year, prepping for whatever their other Open Enrollments are. You know, group has usually a peak in the summer too. Prepping to really understand those options and come out with them to be competitive.
MM: Well, these are, particularly in the employer market, these are long, drawn out conversations, right? You don't just schedule 30 minutes to talk about strategy. I do think that next year there's a high probability with who is advising the Trump administration, and that's largely folks that align themselves with the Paragon Institute and Brian Blaze, who used to be in the White House during Trump 1. They're advocating this whole idea, and you got Representative Scott out of Florida has now introduced a bill that has said, give the subsidy money to people. Well, if that gets legs, I think you have to begin to think as an agent, what the heck would that mean? Right? Because I believe what it's going to do is it's going to expand the definition of what that money can be used for. They're very much believers that why can't I spend that same, my current money on major medical, why can't I just buy short-term limited duration plans? And any insurance agent would be able to tell you what the difference is, but the average consumer won't know, right? But if that's an option, I guarantee you people will buy it thinking that now I have sufficient coverage. And they're going to get, okay, many of you may not be old enough to remember this, but when managed care first rolled in, okay, people got financially bloodied, and that's how they learned to stay within the system. Okay, that's exactly what will happen again. People will make bad choices. They'll get financially hurt and then they'll go, I learned my lesson there. I won't do that again. All right, but it'll expand short-term limited duration, Christian ministry shares, level-funded, association plans —all of those things have been created or bubbled up in an effort to offer alternatives. All right, not all of them work in all situations and there's not any one silver bullet for everyone. That's why you need agents. frankly, that's why you need a professional advisor. But you're right, if you aren't bringing that new strategy conversation to the table, trust me, employers are begging for a new strategy, at least a conversation around it. And if you're not one bringing it, somebody else will, and you'll find yourself kind of all of a sudden your phone won't ring anymore.
AB: I think the key thing here is education. Real, true, reduce the noise and really take time to educate yourself on what you can offer and how you can differentiate yourself.
MM: That's it. That's always been it, actually. You don't go out representing me. You go out representing you. And if you're not on the same side of the table as that employer or that individual acting on their behalf and in their best interest. In other words, if your goal is just to have your commission have a soft pillow landing because you want the subsidies to be enhanced again or not, okay, is not the right priority. The right priority is how do I help this person through this year's decision. We'll worry about next year, next year, right? But you gotta worry about this year now.
AB: Thank you so much for this conversation, Mark. I appreciate you taking the time and I'm excited to continue this conversation with you in other ways. I know we'll see you coming up at BlocBuilder. So I'm excited to keep learning from you.
MM: Absolutely. I will absolutely pitch BlocBuilder. Look, I've been doing this for decades. There have, I have not been to a better conference in the last two of those decades that even comes close to AgencyBloc's. It was a great, great experience. And I didn't get paid to say that.
AB: Well, I appreciate it. I'll give you a nice mug when I see you in person in April. BlocBuilder, April, Fort Lauderdale, be there. Come hang out with Mark and myself. Learn. You really can't miss it.
MM: There you go. Thank you, Allison.
Posted
on Monday, November 24, 2025
in
Inside the Industry
- industry news