DC EKG

"Obamacare Exempt" Plans - STLDI and ACA Coverage: Costs, Choice, and Tradeoffs

Joe Grogan is joined by Michael Cannon (Cato Institute) to break down short-term, limited-duration insurance (STLDI), also known as “Obamacare-exempt” plans. They explain why STLDI can be far cheaper than ACA exchange coverage, how renewal guarantees work, and why allowing more consumer choice can reduce pressure on exchange risk pools.

They also dig into the politics of pre-existing conditions, how ACA rules change insurers' incentives, and why coverage debates often miss the real drivers of cost, access, and quality. The conversation ends with a broader look at public trust, healthcare fear, and how policy choices shape what insurers can and cannot do.

Timestamps / Chapters00:01 – Intro00:23 – Michael Cannon joins + what STLDI is02:27 – STLDI explained: “Obamacare-exempt” plans, renewal guarantees, and lower premiums06:00 – ACA history: why STLDI was restricted07:46 – International comparisons + pre-existing conditions incentives and the Colette Briggs story12:10 – Why healthcare stays broken: regulation, lobbying, and “government-designed” systems16:59 – Subsidies and the politics of pre-existing conditions22:22 – Renewal guarantees, employer tax exclusion, and why Medicare entered the picture30:37 – Public trust after Brian Thompson’s murder and Cannon’s letter41:56 – Wrap-up

In This Conversation


What STLDI is and how it compares to ACA exchange plans


Why renewal guarantees matter for long-term protection


Risk pools, affordability, and why the “junk insurance” debate persists


Pre-existing conditions, politics, and how incentives affect networks and access


Why employer-based coverage and Medicare policy shaped today’s system

Key Takeaways


STLDI is a legal, consumer-driven coverage option that can reduce premiums and expand choice.


Renewal guarantees are a major consumer protection that changes the long-term risk story.


Pre-existing conditions policy is often debated emotionally, but incentives determine outcomes.

About Our GuestMichael Cannon is the Director of Health Policy Studies at the Cato Institute and a leading voice on the ACA, health insurance regulation, and market-based health reforms.

Podcast TitleDC EKG with Joe Grogan: A Healthcare Policy Podcast

Episode124

Episode TitleRyan Long on the ACA Subsidy Fight, Phantom Enrollees, and Reforming 340B

Episode DescriptionJoe Grogan is joined by Ryan Long of Paragon Health Institute and the University of Southern California to break down two fights shaping health policy right now: a California wealth tax pitch framed as a health care fix, and the battle over extending enhanced Affordable Care Act subsidies.

They unpack how enhanced subsidies changed who qualifies, why zero-premium plans opened the door to broker-driven enrollment and fraud, and why the medical loss ratio creates perverse incentives that can push premiums higher. They also explain how silver loading and cost-sharing reduction policy distort the exchange market, and what reforms could lower costs without writing a blank check.

The episode closes with Ryan's latest work on the 340B program, including why drug arbitrage rewards hospitals with a stronger commercial mix and can fuel consolidation, and why direct, targeted assistance could better support hospitals that truly serve low-income and rural patients.

Chapters and Timestamps00:01 Intro00:23 Welcome, and what is on the agenda01:25 California wealth tax and structural deficits11:20 Enhanced ACA subsidies and the shutdown fight16:54 Income caps, zero premium plans, and phantom enrollees21:50 Fraud, Medicaid exposure, and public trust30:39 Medical loss ratio incentives and ACA market fixes38:41 340B: how arbitrage works and why it drives consolidation44:51 What reform could look like47:20 Closing

SEO KeywordsAffordable Care Act, ACA subsidies, enhanced subsidies, premium tax credits, exchange plans, zero premium plans, phantom enrollees, medical loss ratio, cost sharing reduction, silver loading, Medicaid fraud, Minnesota fraud, California wealth tax, 340B program, drug arbitrage, hospital consolidation, site neutral payments, commercial mix, Medicare Trust Fund

About Our GuestRyan Long is a health policy expert with experience on Capitol Hill, including years in the Speaker's office and on the House Energy and Commerce Committee. He is affiliated with Paragon Health Institute and the University of Southern California.

CreditsSponsor: Survivors for SolutionsExecutive Producer: John “CZ” Czwartacki, DC EKG PodcastProducer: Julie Riga, Stay on Course Studios, https://www.stayoncourse.studio

DC EKG with Joe Grogan: A Healthcare Policy Podcast

Ep. 122

In this episode of DC EKG with Joe Grogan: A Healthcare Policy Podcast, Joe recaps the first Healthcare AI Policy Summit, held on December 10th in Washington, DC, with his co-host for the event, Naomi Lopez, founder of Nexus Policy Consulting.

They walk through the big themes shaping healthcare AI right now: how HHS is approaching AI adoption, what real regulatory clarity could look like, and how new federal initiatives like ACCESS and TEMPO may reshape chronic disease management for Medicare patients.

Joe and Naomi unpack HHS Deputy Secretary Jim O’Neill’s view of AI in government, from using large models to improve physician productivity, payment integrity, and care coordination to managing privacy and re-identification risk when working with federal health data.

They dig into the ACCESS Medicare payment model and the FDA TEMPO initiative, explaining how these pilots test AI and machine learning tools in real-world chronic disease management (hypertension, diabetes, musculoskeletal pain, and depression), and what that means for Medicare payment models, FDA oversight, and healthcare innovation.

The conversation then widens to physician burnout, interoperability, rural care, and the role of states and federal preemption in setting the rules for healthcare AI. If you care about the real-world impact of healthcare AI on policy, payment, and patients, this episode offers a clear, practical summary of what the summit revealed and what to watch next.

Today Joe and Naomi cover:


Jim O’Neill’s vision for AI at HHS, including internal AI adoption and keeping a direct line open for small innovators.


ACCESS and TEMPO as new federal test beds for AI in chronic disease management and Medicare payment.


How wearables, remote monitoring, and “virtual ICU” models can support aging in place and reduce pressure on state budgets.


Ways AI can reduce documentation burden, support care coordination, and act as a first-line triage tool without replacing clinicians.


The emerging idea of personal AI agents that help patients navigate the system and share the right data with clinicians.


How AI-enabled diagnostics and tools can expand access in rural and underserved communities.


Why interoperability, ONC’s API rules, and the balance between state AI regulation and federal preemption will shape how quickly these tools scale.


The potential for tech companies to become Medicare Part B providers under ACCESS, and what that means for reimbursement and competition.

Key Takeaways:

Healthcare AI is being built into policy through programs like ACCESS and TEMPO, tying AI tools to Medicare payment and FDA pathways in chronic disease management.


Regulatory clarity and predictable routes from FDA clearance to Medicare reimbursement are essential for sustained AI adoption.


AI is currently most valuable as a force multiplier for physician productivity, taking on administrative and analytic work so clinicians can focus on patients.


Personal AI agents may become a primary interface between patients and the health system, coordinating data, benefits, and care.


Rural and underserved communities could benefit significantly if payment and regulatory rules support AI-enabled diagnostics and remote care.


Interoperability, state AI laws, and federal preemption will determine whether healthcare AI stays in pilots or reaches patients nationwide.

Joe's guest, Naomi Lopez, is the founder of Nexus Policy Consulting and a leading voice in healthcare policy, healthcare AI, and state health reform. She co-founded a healthcare AI working group with Joe Grogan and co-hosted the inaugural Healthcare AI Policy Summit on December 10th in Washington, DC.

In Episode 123 of DC EKG, Joe Grogan sits down with Jackson Hammond (Senior Policy Analyst, Paragon Health Institute) to unpack what the latest CMS National Health Expenditure (NHE) data says about where U.S. health care is headed.

They break down the June 2025 NHE release, compare it to Jackson’s earlier “Paragon Prognosis” analysis, and explain what changed, what didn’t, and what it means for affordability, Medicare, Medicaid, and long-run fiscal pressure.

They also connect the spending outlook to Jackson’s paper, “How to Reform the CMS Innovation Center with a Choice and Competition Approach,” and debate whether CMMI is bending the cost curve or just adding bureaucracy without accountability. Jackson argues we should aim for health care so affordable you barely need insurance.

Chapters / Timestamps  00:00 – Intro + welcome  00:55 – Jackson’s background: how he got into health policy  03:39 – Focus areas: Medicare, hospitals, drug pricing, PBMs, 340B  05:14 – What the NHE report is showing  06:14 – $5.2T → $5.6T → $8.6T: why the trajectory matters  08:00 – Why health spending isn’t really “optional”  10:11 – Where the money is going: payer mix + per-enrollee costs  12:23 – Medicaid costs, provider taxes, and state financing tactics  15:58 – Medicare spending pressure and fiscal risk  21:06 – Misconception: “coverage = care”  26:18 – Why provider payments keep rising (post-COVID demand + consolidation)  33:01 – Rural care, consolidation, and the REH / hub-and-spoke model  40:08 – Drug pricing: retrospective vs prospective MFN  49:20 – 2026 outlook + closing thanks

In This Conversation  • NHE 2025: what the June 2025 data confirms about spending growth and the federal share.  • Rising prices, flat health: why prices climb while outcomes lag.  • Medicare and Medicaid: why they remain major budget drivers.  • Coverage vs access: why an insurance card doesn’t guarantee care or better health.  • Hospitals and consolidation: what’s driving higher payments and fewer choices.  • Rural vs urban: why patients bypass local hospitals and what a better model could look like.  • Drug pricing: what MFN approaches might mean for costs and innovation.  • 2026: what Jackson expects next and what reform could realistically look like.

Key Takeaways  • NHE data points to continued, unsustainable spending growth.  • Medicare and Medicaid drive long-term budget pressure.  • Consolidation and payment incentives shape prices as much as utilization.  • CMMI reform hinges on accountability, choice, and competition.  • Smarter drug pricing policy should lower costs without undermining innovation.

About Our Guest  Jackson Hammond is a Senior Policy Analyst at the Paragon Health Institute focused on health spending, CMS policy, and reforms centered on choice, competition, and patient-centered care. He authors Paragon’s “Paragon Prognosis” analyses and wrote “How to Reform the CMS Innovation Center with a Choice and Competition Approach.”

In this episode of DC EKG with Joe Grogan: A Healthcare Policy Podcast, Joe sits down with health economist Tony LoSasso to dissect what serious, workable Obamacare reforms could look like without blowing up the Affordable Care Act entirely. They dig into the structure of healthcare subsidies, why current premium tax credits dull price sensitivity, and how that undermines insurance competition, drives up healthcare costs, and threatens the law's fiscal sustainability.

Tony lays out a path to modernize the ACA with defined-contribution-style subsidies, patient-directed “health freedom” accounts, and targeted support for people with preexisting conditions through high-risk pools, rather than hiding transfer programs inside community-rated premiums. Along the way, they tackle essential health benefits, community rating, Medicare pricing, certificate-of-need laws, and growing hospital market concentration, and ask what a real bipartisan healthcare reform deal might look like in today’s political climate.