PatientPay CEO Tom Furr Featured on the Hospital Finance Podcast

What the ACA Enrollment Shift Actually Looks Like

When ACA enrollment started generating headlines late last year, most coverage focused on the risk of patients going uninsured. Tom dug into the data and found a more nuanced picture, one with different but equally significant implications for providers.

Rather than dropping coverage entirely, the majority of people leaving ACA marketplace plans appear to be transitioning back into employer-sponsored insurance. The private insurance market grew by roughly 1.4 million covered lives from 2024 to 2025. The real issue is not whether these patients have coverage. It is what kind of coverage they have.

Key numbers from the episode:

• 1.2 to 1.4 million people have left ACA marketplace plans
• Private insurance market grew by approximately 1.4 million covered lives from 2024 to 2025
• 59% of employers are actively looking for ways to control healthcare costs
• High-deductible health plans are their primary tool for doing it

The HDHP Surge: Numbers Providers Need to Know

The shift back to employer-sponsored coverage is accelerating the adoption of high-deductible health plans at a pace the industry has not seen before. Tom walked through the trajectory in detail.

• 27 to 29% of covered lives were on an HDHP in 2024
• That figure climbed to 33% in 2025
• HDHPs are projected to reach 40%+ of employer-sponsored plans in 2026, a 20%+ single-year increase
• Within three years, HDHPs could represent 50% of the total market

For providers, that trajectory translates directly into growing patient balances that cannot be resolved at the point of service. Every encounter generates a claims-and-adjudication process, with patient responsibility determined on the back end, and that responsibility is getting larger.

"Deductibles are becoming more and more a larger part of the dollars that are paid to providers," Tom noted. "The individual is now, as a standalone, the largest payer into the system of healthcare."

What Providers Need to Do Now

Tom outlined a three-part response for practices and health systems preparing for this shift.

1. Front-end estimation. Patients on HDHPs are making real financial decisions before and after care. Giving them a credible estimate upfront removes uncertainty and sets expectations. "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."

2. Statements that align with the EOB. Confusion, not unwillingness, is the primary driver of unpaid patient balances. PatientPay works with organizations that integrate the Explanation of Benefits directly into the patient statement, so patients can confirm what they owe before they pay it.

3. Payment flexibility that matches how HSAs actually work. Most HDHP enrollees carry an HSA, but balances are limited. A patient who owes $1,000 may only have $200 available in a given month. A structured payment plan is not a discount. It is the path to full collection.

• 72% of patients are less likely to miss payments when healthcare expenses are accessible in one place
• 77% of patients want installment options for unexpected expenses
• HSA-aware payment plans address both the balance visibility problem and the monthly cash flow constraint simultaneously

"Most people want to pay their healthcare bills," Tom said. "To make it as frictionless as possible to understand the bill, and as frictionless as possible to pay the bill, that is mission critical."

Listen to the Full Episode

Catch the full conversation on the Hospital Finance Podcast, where Kelly Wisness and Tom cover the complete enrollment data, long-term HDHP projections, and the operational playbook for providers navigating the shift. The Hospital Finance Podcast is a production of Besler, now part of Kodiak Solutions.