Health Benefits 2.0: Tailored to a Mobile Workforce

One of the themes that we have been tracking and talking a lot about is this notion of consumers as a new class of payer. And what we mean by that is both consumers paying more out of pocket, as we all know more of the healthcare burden is now being borne by individual consumers. It also refers to this concept of consumers shopping. So given a budget, how can I actually make the right selections for myself with various healthcare products and services? So in that vein, we all know that one of the most compelling examples of this trend is ICRA, ICHRA, which we're going to unpack for the crowd.

我们一直在关注并讨论的一个主题是，消费者正成为一种新的支付群体。我们的意思是，消费者现在需要承担更多的医疗费用，我们都知道，越来越多的医疗负担开始由个人消费者承担。这个趋势同时也涉及消费者选择的概念。在有预算的情况下，如何为自己合理地选择各种医疗产品和服务？基于这种背景，我们都知道一个极具代表性的例子就是ICRA和ICHRA，接下来我们将为大家详细讲解这个趋势。

What are some of the factors that have led us to the system that we all deal with today in the employer-sponsored insurance world? Yeah, it's a great place to start because when you really trace it back, the consumer started as payer in the 1800s and early 1900s before we had insurance, before employers were paying for anything, they would just go to the doctor and pay out of pocket for services. And this was fine for a while, but as medicine got better and technology advanced, what ended up happening was you'd have a middle class worker go to the hospital and have a bill that was going to eat up six months of their salary.

导致我们今天所面临的雇主提供保险制度的一些因素是什么？是的，这是一个很好的起点，因为如果追溯源头，你会发现在1800年代和1900年代初期，还没有保险体系，也没有雇主为任何医疗费用买单，那时消费者自己支付医疗费用。他们会直接去看医生，并自己支付服务费用。这个方式维持了一段时间，但随着医学进步和技术的提升，情况变化了。中产阶级的工人可能因住院而收到一张账单，而这张账单的金额可能会耗尽他们半年的工资。

The US, unlike most of the world, decided not to go with the government-sponsored healthcare program outside of the very poor with Medicaid and the very old with Medicare. There was this void that was left by the government and insurers took note. And so when you actually looked at the very first forms of health insurance, really interesting, you had property insurers and life insurers try to get into the health insurance space and they sold directly to consumers originally. But the problem was, well, it turns out the only people who bought health insurance were already sick or they had broken a leg.

与世界大多数国家不同，美国政府选择不为大众提供政府支持的医疗服务，只有非常贫困的人可以通过“医疗补助”（Medicaid）获得帮助，而年长者则依靠“医疗保险”（Medicare）。政府留下的这个空缺引起了保险公司的注意。因此，当你回顾最初的健康保险形式时，会发现一些有趣的现象：当时，财产保险公司和人寿保险公司尝试进入健康保险领域，并直接向消费者销售产品。但问题在于，事实证明，只有那些已经生病的人或骨折的人会购买健康保险。

And then 100 years ago, there's really brilliant insight at the time. Blue Cross, 1929 said, hey, maybe we sell to employers. There's enough of them that we can generate a pretty big risk pool. We have enough healthy people to offset the cost for the sick. Employers are looking for new ways to recruit and retain talent. And it was super logical. But 1929, we had our first employer-sponsored health plans with Blue Cross. And people forget, the first 10 years, it was like a super niche product that nobody used.

大约100年前，有一个非常聪明的想法诞生了。蓝十字会在1929年提出，不如我们向雇主出售健康保险。雇主够多，我们就能建立一个相当大的风险池。健康的人越多，就越能平衡患病者的费用。雇主们也在寻找新的方法来吸引和留住人才。这个想法非常合理。所以在1929年，我们有了第一个由雇主赞助的健康保险计划，与蓝十字会合作。不过，很多人可能不知道，最初的10年，这其实是一个很小众的产品，几乎没人使用。

And it wasn't actually until World War II where you had a lot of the labor market going to fight in Europe. And you had Congress issuing a wage freeze. And what happened was because labor was scarce, but they couldn't raise salaries to get new workers. And they had to find new ways to compete for talent. And health insurance was a way to actually have this loophole where we could give a better benefit, attract workers. Congress got wise and said, hey, maybe we should just make it pre-tax and then we won't have to worry about it at all. And so they did. And sure enough, 100 years later, we've kept the same system ever since.

直到第二次世界大战期间，许多劳动力前往欧洲参战，国会颁布了工资冻结政策后，事情才发生了变化。由于劳动力短缺，但没法通过提高工资来吸引新员工，雇主们不得不寻找新的方法来竞争人才。健康保险成为了一个吸引劳动者的途径，因为可以通过提供更好的福利来吸引更多员工。国会意识到了这一点，于是决定将健康保险的费用设为税前项目，这样就不用担心相关的问题。这个制度一直沿用至今，已有近百年历史。

And so what kind of began is this genius marketing move from Blue Cross and then kind of an accident of history with Congress and these World Wars ended up cementing this model that we have today that is very unique amongst most Western countries. Fascinating. Very well said.

这是一项天才的市场营销举措，由蓝十字公司发起，再加上历史偶然事件，即国会的决定和世界大战，这些共同促成了我们今天这个在大多数西方国家中都独一无二的模式。这真是令人着迷。说得非常好。

One of the things that we find most attractive about this market is that how big it is. And most markets and health care, you have a very finite set of buyers. If you're selling to insurance companies, there's only a few hundred that really matter. If you're selling to hospitals, there's only a few thousand that matter. But in this world, it's literally like millions, if not tens of millions of companies, that could be the end customers. And so how do you guys think about that landscape? What do you think about who is the ideal potential customer that might benefit from some of these novel solutions like what we're going to talk about with Acra?

我们发现这个市场最吸引人的地方之一是它的规模有多大。在大多数市场和医疗保健领域，买家是非常有限的。如果你在向保险公司销售，真正重要的也只有几百家。如果你在向医院销售，真正重要的也只有几千家。但在这个领域，最终客户可能是数百万甚至上千万家公司。那么，你们是如何看待这个市场的呢？在你们看来，谁是那些最有可能从我们将与Acra讨论的新颖解决方案中受益的理想潜在客户？

When we were starting Thatch, so one of the things that we were thinking about was we were building Thatch for us, which at the time we're busy founders. We were trying to get health care for our team, get a good plan that worked for everybody, and we had a remote team and spread out across the country. And so we picked a plan out of Texas where Chris was living at the time. We started hiring people in New York and California and Washington and all over the place. And we found that experience was terrible. So we spent a ton of money on a health insurance plan. We thought we were getting everybody really great quality of health care. People started at the company and nobody was happy because their doctors weren't covered or whatever.

当我们开始创办Thatch时，我们考虑的其中一件事就是我们正在为自己打造Thatch。那时我们是忙碌的创始人，正在努力为团队争取医疗保险，希望能够找到一个适合每个人的好方案。我们的团队是远程工作，分布在全国各地。因此，我们选择了一个来自德克萨斯州的保险计划，因为当时Chris就住在那里。随后，我们开始在纽约、加利福尼亚、华盛顿和其他各地招人。结果我们发现这个体验很糟糕。我们花了很多钱在健康保险计划上，以为可以为大家提供优质的医疗保障。结果新员工入职后都不满意，因为他们的医生不包括在保险范围内等等问题。

And so we really thought that was the segment that Acra was a good fit for. It was like early stage companies, distributed teams. The thing that's been surprising is we've been kind of pulled out market. We're seeing more and more demand from larger and larger companies. And so on Thatch now, we've got companies ranging from funded tech startups, Y Combinator, AI companies, up to mid-market trucking companies in the Midwest or solar installation companies on the West Coast or marketing agencies, dental clinics and so forth. And we really think Acra is a fit for companies of all shapes and sizes. Are there broader industry trends or tailwinds that are impacting the way that employers are thinking about insurance that you think is creating this tipping point for the demand for new solutions? Yeah, absolutely. The labor market has evolved quite a bit from a world where people stayed at the same job for most of their lives to one where today you see the rise of the gig economy and remote work and flexible working arrangements. But one thing that hasn't changed with it is the way we do health benefits.

我们一开始认为 Acra 非常适合早期公司或分布式团队。但令人惊讶的是，我们逐渐被市场推向更广阔的方向。现在，在 Thatch 平台上，我们的客户从获得融资的科技初创企业、Y Combinator 和 AI 公司，到中西部的中型卡车公司、西海岸的太阳能安装公司，再到营销机构、牙科诊所等等。我们认为 Acra 适合各种规模和类型的公司。有没有更广泛的行业趋势或顺风，对雇主思考保险的方式产生了影响，从而推动对新解决方案的需求达到一个转折点？当然，有的。劳动力市场从过去人们在一个工作岗位上待一辈子的情况，逐渐演变为如今的零工经济、远程工作和灵活工作安排的兴起。但在此过程中，医保福利的处理方式却没有随之一同发生变化。

And so with the workforce more mobile than ever, you have this situation today where one out of six Americans actually stays in a job they would otherwise leave for fear of losing their health care coverage. One of the things that becomes really intriguing and interesting is what if like a 401K or something like that or an HSA, what if you could actually bring your health care coverage with you from job to job rather than being kind of shackled to your employer? And so as the labor market evolves, we see that as one big source of friction for the old model. We're literally just talking to someone today, funnily enough, who we had quoted this stat to. And what they had told us was this was actually the exact situation I was in because my wife was pregnant and we had a very intensive series of procedures.

随着劳动力的流动性比以往任何时候都更高，如今美国有六分之一的人因为担心失去医疗保险而留在工作岗位上，而不是离开。一个非常引人入胜且有趣的想法是，如果医疗保险像401K退休储蓄计划或健康储蓄账户（HSA）那样，可以随工作一起转移，而不是被雇主绑住，这将会如何？随着劳动力市场的发展，我们发现这是老模式中的一个主要摩擦点。碰巧的是，今天我们和一个人交谈时提到了这个统计数据，而他告诉我们，这正是他所面临的情况，因为他的妻子当时怀孕了，他们需要进行一系列非常复杂的治疗。

And we had to say the job because if we change jobs and there was some kind of disruption in coverage, a bill for delivering a baby when you pay it out of pocket can bankrupt you. And so that's one anecdote. As soon to be a new father myself, why are they really resonated with me? So we're dancing around this concept of Ikra. What do we go ahead and explain? What is Ikra? How did it come to be? And what is sort of the state of the state in the Ikra market? Ikra is a law that brought into effect four years ago that makes possible for the first time ever for employers to instead of choosing all the benefits for their team, just give them tax-free dollars that they can spend the way that they want. So rather than going out and choosing a group health plan for them, they instead say, hey, Julie, you get $1,000 a month and you can spend it on the health insurance and dental insurance you want.

我们必须谈论工作的问题，因为如果我们换工作，并且在保险覆盖上出现了某种中断，那么自付分娩费用就可能让你破产。这只是一个例子。作为一名准爸爸，这个话题引起了我的共鸣。我们正在探讨'Ikra'这个概念。什么是Ikra？它是如何形成的？目前Ikra市场的情况是怎样的？ Ikra是一项四年前实施的法律，它首次让雇主可以不为团队选择所有福利，而是给他们免税的资金，让他们按照自己的意愿使用。也就是说，雇主不用为员工选择团体健康计划，而是告诉他们，比如“嘿，Julie，你每个月可以得到1000美元，你可以把这笔钱用于你自己想要的健康保险和牙科保险上。”

Jay, you get $800 a month. You can spend it the way that you want. And the cool thing about Ikra is the money that's left over. You can actually allocate to other costs too. So whether that's a prescription or braces for your kids or maybe it's therapy, whatever is important to you, that's the thing Ikra lets you do. And basically just to put that into context, most of us work for a company where every employee is given the option of maybe like two, maybe three different plans. Like a one size fits all fine. Yeah. And it's totally monolithic. Everyone gets the same thing. And more so, what you guys are saying earlier about just the trend towards remote work, even if you live outside of the state of the organization that you work for, you are still presented with basically the same plans.

杰，你每个月可以获得800美元。你可以根据自己的意愿来支配这些钱。Ikra的一个好处是，你可以将剩下的钱用于其他费用。不论是药物处方、孩子的牙套还是心理治疗，只要是你认为重要的，Ikra都能帮你实现。简单来说，我们大多数人工作的公司通常会给每位员工提供两到三种计划的选择，这些计划往往是“一刀切”，千篇一律的。就算是远程工作，如果你住在公司所在州之外，你仍然会面对基本相同的计划选项。

And so your networks are going to be constructed for that reason, et cetera. And so what you're saying is that this is a means to basically allow people to shop for plans that are sort of both personalized to their own needs and then also localized to where they live. Right? That's exactly right. And we've seen this trend play out in the retirement space with the evolution of the workforce. I mean, most listeners may not remember pensions, but they were actually the kind of default strategy that businesses use to help their employees safer retirement. They were fabulously expensive. They required the company to actually manage it in house. And as the workforce grew more dynamic and left jobs, went between jobs more frequently, it was harder to actually manage these funds and many of them went underwater.

所以，你的网络是为了这个原因而构建的，等等。所以你在说的是，这是一种方式，基本上允许人们选择符合个人需求的计划，并且这些计划还能贴合他们的居住地，对吧？完全正确。我们也在退休领域看到了这种趋势随着劳动力演变而展开。我想，大多数听众可能不记得养老金了，但它们曾经是企业帮助员工储蓄退休资金的默认策略。它们极其昂贵，公司需要在内部管理。随着劳动力变得更具动态性，人们更频繁地离职和转换工作，这使得管理这些资金变得更加困难，许多基金都出现了资不抵债的情况。

And so enter 401ks, away from companies to give their teams tax free money. They could control and predict their costs more effectively, employees win because they're actually able to choose a retirement strategy that makes a lot of sense for them. They could bring it from job to job. And today there's $7 trillion in 401k accounts. And so we're seeing signs that the same shift from defined benefit to defined contribution that we saw in retirement happening here in health care. And it's really for a lot of the same reasons where the old mold is not necessarily fitting the emerging workforce as well as it used to.

于是，401K计划问世，让企业能够为员工提供免税的资金。企业可以更有效地控制和预测成本，而员工也受益，因为他们可以选择真正适合自己的退休策略，并且可以随工作变动而携带。如今，401K账户中已有7万亿美元的资金。我们也看到类似的转变，如同从「固定福利计划」到「固定缴费计划」的转变一样，现在这种变化也在医疗保健领域发生。很大程度上，这是因为旧的模式已经不再适应不断变化的劳动力市场。

Iqra in many ways is kind of this continuation of the idea of an HSA where HSA FSA focusing on out of pocket spend, but Iqra instead expanding to the full medical spend so that allows an employee to allocate between their out of pocket expenses and their medical insurance. It's almost allowing the consumer to realize an even larger potential with the sum of the money that they're getting access to.

在许多方面，Iqra可以看作是HSA（健康储蓄账户）理念的一种延续。HSA和FSA（灵活支出账户）主要关注自付费用，而Iqra则扩展到了全部医疗花费。这使员工能够在自付费用和医疗保险之间进行分配。它几乎让消费者能够更充分地利用他们可以使用的资金。

So we've spoken about the friction of employer-sponsored health care for the employer and the employee. I'd love to dig into that. So a lot of times we partner with a lot of entrepreneurs. They raise funding. They get capital in the bank. They start looking at their operating expenses and they quickly realize that perhaps their first, their first highest expense is employees. But number two or number three is health insurance and they're shocked. And yet when you go down to the employee level exactly as you described, there's high friction. You're not always getting value. And if you look at the data, employer-sponsored health care is outpacing inflation over the last 10 years is rapidly increasing. So it feels like we're spending more and we're getting less.

我们已经讨论过雇主提供的医疗保险对雇主和雇员造成的摩擦。我很想深入探讨这个问题。很多时候，我们与许多企业家合作。他们筹集资金，银行里有了资本，然后开始查看他们的运营费用，很快意识到可能他们最大的支出是员工。第二或第三大的支出就是健康保险，这让他们感到震惊。然而，正如您所描述的，在员工层面，也存在很大的摩擦。他们并不总是能获得相应的价值。根据数据显示，过去十年里，雇主提供的医疗保险费用增长速度超过了通货膨胀，迅速增加。所以感觉我们花的钱更多，但得到的却更少。

And then you present Iqra as this idea that kind of unbundles and unlocks that. Is it a silver bullet? Help us understand what it is. I don't think Iqra is a silver bullet. I mean, you know, the thing that you're doing is returning power to the people and giving them choice. So you're giving them health care dollars that they can spend the way that they want. The downside or I think a lot of the criticism around Iqra in particular has been if you have all of these choices, how does one know how to spend that money? And so I think that's where technology comes in.

然后你介绍Iqra这个想法，它有点像是解开和释放现状。它是一个万能灵药吗？帮我们理解一下这是什么。我不认为Iqra是万能灵药。其实，你知道，你做的事情是将权力归还给人民，给他们选择的自由。你给他们提供医疗资金，让他们可以按照自己的意愿花费。但不足之处或者说对Iqra的许多批评在于：如果有这么多选择，人们怎么知道该如何花费这些钱呢？我认为这就是技术可以发挥作用的地方。

And so we really think Iqra is four years in and has been some adoption, but probably not the adoption curve that folks initially expect and you think that's mostly wise. The tools haven't been there to make it easy for people to understand. There's my budget. I'm going to choose these options allocated this way. So let's talk about that.

我们认为 Iqra 项目已经开展四年，并且已经有了一些应用，但可能还没有达到人们最初所期望的接受程度，而这大多是有原因的。因为目前还缺乏能够让人们轻松理解的工具。比如说“这是我的预算，我会以这种方式选择分配这些选项。”所以让我们来谈谈这个问题。

So you guys are a pretty unique team, you know, health care domain expertise. We believe that Adam might be the only human on the planet who has actually worked at both the health insurance company and Stripe. And so you guys are taking a FinTech lens to this problem space. So talk to us more about like, why is this a FinTech problem? And what are some of the hard things that need to be solved by taking that unique approach? Well, Iqra fundamentally is give your team money to pay for health care, which sounds great in principle, but in practice, like, how do you give them the team? Or how do you give them the money? How much money do you give them? How do you actually ensure that they're spending that money on health care and not spending it on iPads? And all of those are technology problems.

你们这个团队非常独特，具有医疗领域的专业知识。据我们所知，Adam 可能是地球上唯一在健康保险公司和 Stripe 都工作过的人。因此，你们正在从金融科技的角度来看待这一问题。那么请跟我们讨论一下，为什么这是一个金融科技的问题？采用这种独特的方法有哪些需要解决的困难之处呢？Iqra 的核心理念是给你的团队提供资金以支付医疗费用，这在原则上听起来很棒，但在实践中，如何给他们团队？或者如何给他们钱？给他们多少钱？如何确保他们实际将这些钱花在医疗上，而不是买 iPad？所有这些都是技术问题。

And so when we started building that, you know, going out to the market and talking to people who were trying to implement Iqra and having a hard time, those were a lot of the problems that we were hearing. And so yeah, we just started hiring great FinTech engineers from companies like Stripe and Ramp and Brax and so forth that really understood how to solve those problems. And you also mentioned that, you know, we're only four years in to this new policy being in place. And when you look back at the history of sort of novel insurance products in general, so you have things like Medicare Advantage, which was for the first time delegating private company sort of responsibilities for administering the senior insurance products, you also have it had ACA, which is obviously directly relevant to the Accra product, but you had the ACA marketplaces that went into effect with Obamacare.

所以，当我们开始构建这个项目时，我们会去市场上与那些尝试实施Iqra但遇到困难的人交流。我们听到了许多这样的问题。因此，我们开始从像Stripe、Ramp和Brax这样的公司招聘优秀的金融科技工程师，他们真正懂得如何解决这些问题。你提到这项新政策刚刚实施四年，而回顾新型保险产品的历史，比如医疗保险优势计划，这个计划首次将管理老年保险产品的责任委托给私营公司。还有《平价医疗法案》（ACA），这显然与Accra产品直接相关，在奥巴马医保框架下，ACA市场也开始生效。

And in both cases, it took, you know, arguably at least a decade, if not more, for those to ultimately get to sort of mass market appeal and like true growth trajectories that made sense from a startup and builder perspective. So what gave you guys the conviction that perhaps that could happen more quickly in Iqra? And what are you actually seeing play out sort of in the market that shows a higher trajectory than perhaps some of those other areas?

在这两种情况下，可以说至少花了十年，甚至更久，这些产品才最终获得大众市场的吸引力，并形成从创业和建设者角度看来合理的真正增长轨迹。那么，是什么让你们相信这种情况在Iqra能够更快发生呢？你们在市场上实际看到了哪些迹象，表明其增长路径可能比其他领域更高呢？

Yeah, it's a great question. And we really kind of see it as three reasons. One, which you alluded to earlier, which is just that like the employer market is larger than Medicare. It's larger than ACA combined. It's just the biggest market. And so there's so much room for improvement. And then the second one being that, you know, group insurance rates are rising at the fastest rate, perhaps in history. And so Iqra offers an opportunity to kind of solve this pretty hair on fire problem of like bending the healthcare cost curve, saving millions of dollars. And for that reason, it's just such a compelling value proposition from a business perspective.

是的，这是个很好的问题。我们实际上认为有三个原因。第一个是你之前提到过的，就是雇主市场比医保市场更大，甚至比《平价医疗法案》（ACA）和医保加起来还要大。这是最大的市场，因此有很大的改进空间。第二个原因是，团体保险费率正以有史以来最快的速度上涨。因此，Iqra提供了一个解决这个非常紧迫问题的机会，就是扭转医疗成本曲线，节省数百万美元。从商业角度来看，这真的是一个非常吸引人的价值主张。

But the third one, which really we're seeing from speaking with growth leaders at carriers and kind of really thinking through health plan strategy is because Medicare Advantage is seeing such big headwinds. And because the ACA is kind of starting to slow down. I mean, Medicare Advantage had mid single digit growth last year. Certainly the ACA is slowing down. We're seeing maybe the enhanced subsidies will expire. So then the question that's on the all the carriers mind, okay, well, like we're seeing stagnation in the ASO kind of largely fully insured markets, small groups blowing up, MA. That'll take the determination. Exactly Medicaid, redeterminations.

但第三点，我们在与保险公司的增长领导者交谈并深入思考健康计划战略时注意到，主要是因为Medicare Advantage（医疗保险优势计划）正面临巨大阻力。而且，《可负担医疗法案》（ACA）似乎也开始放缓。去年，Medicare Advantage的增长率是中等个位数。显然，ACA的增长正在放缓，我们可能会看到增加的补贴即将到期。那么，各家保险公司都会面临的问题是，我们在自筹健康保险市场中看到停滞，许多小团体计划出现问题，而Medicare Advantage（MA）的未来也充满不确定性，尤其是关于Medicaid资格重新审核的决定。

So where's the next growth opportunity? And there's only one pocket of growth that is small today, but is seeing triple digit growth year over year. That could be that next big secular tail when for the next 10 years. And as a result, these carriers are saying, I need to shift from thinking of Iqra as a defensive strategy where maybe it's going to cannibalize my group business to actually, how can I use that to play offense? How can I get into those employer accounts that have been traditionally really hard to penetrate? The carriers that we're talking to are looking at it as like, actually, this is the only way we can grow. And for that reason, that's probably the biggest tailwind that we have.

那么，下一轮增长机会在哪里？目前只有一个增长领域虽小，但每年增长率达到了三位数。这可能会成为未来十年里的一个重要长期增长的趋势。因此，这些运营商表示，他们需要转变观念，不再把Iqra仅仅视作一种防御策略——以往担心它可能会削弱他们的团体业务，而是要考虑如何利用它来进攻。他们想要进入那些传统上很难渗透的公司账户。我们交谈的运营商认为，这实际上是他们唯一的增长途径。正因为如此，这可能是我们面临的最大推动力。

It's a very simple product in many ways in terms of the concept, but in order to insert it properly into the ecosystem, you guys need to like play with a lot of folks. So like, tell us a little bit more about the ecosystem and who needs to buy in and like play nice with you guys for this to ultimately work and get the scale. I mean, technically, I think the biggest group that needs to play in and work with us is carriers. And so we're integrating right now directly with a number of carriers to handle enrollments. And so, you know, the world today is one where individuals with Iqra typically have had to go to healthcare.gov and try and navigate by themselves with a budget.

这在概念上是一个非常简单的产品，但要将其正确地融入生态系统中，你们需要与许多人合作。请稍微介绍一下这个生态系统，以及需要谁的支持和配合，才能使产品最终成功推广并达到规模。技术上来说，我认为最需要与我们合作的一大群体是运营商。因此，我们目前正在直接与多家运营商进行整合以处理登记工作。如今的世界是这样的，拥有Iqra的人通常需要到healthcare.gov网站自行浏览并根据预算进行操作。

And so their employer tells them, you've got $1,200. I visit healthcare.gov. I try and pick from the list of plans. And then I have to manage the enrollment myself. And so instead, we think, you know, the way that you scale Iqra and really grow it is by integrating behind the scenes with the insurance companies and making it easy for people to come to that. Now they just, you know, pick a plan, select the health, dental, and vision they want. And then they get a debit card in the mail for the money that's left over.

他们的雇主告诉他们，你们有1200美元。我访问了healthcare.gov，尝试从那些计划中选择一个，然后我还得自己管理注册操作。相反，我们认为，扩展和真正发展Iqra的方法是与保险公司在后台整合，使人们能够更方便地进行选择。现在，他们只需选择一个计划，选定自己想要的医疗、牙科和视力保险，然后他们就会收到一张寄来的借记卡，上面有剩余的金额。

So carriers are a big one. And the other big one are banking partners so that we're able to facilitate the money movement, you know, handle the funds that are left over so people can use that at the pharmacy or paying co-pay or whatever it is. I was going to add, you know, it's following a similar trajectory continuing the HSA analogy. So a close friend and advisor Roy Ramthun, he's the department of the Treasury, oversaw the implementation of HSA's. And I remember asking him, four years in, okay, you had your government projections, like, how were they? Were they overestimates or underestimates? And he told me, oh, yeah, we way overestimated it four years in.

运营商在这里扮演重要角色。另一个关键角色是银行合作伙伴，我们能够通过他们来促进资金流动，比如处理剩余资金，让人们可以在药房使用或支付自付费用等等。我想补充一点，这与健康储蓄账户（HSA）的发展轨迹类似。我的一位亲密朋友兼顾问Roy Ramthun，曾是财政部的官员，负责监督HSA的实施。我记得在四年后问他，你们政府的预测怎么样，是高估还是低估了呢？他告诉我，哦，是的，我们在四年后的确严重高估了。

And I was like, oh, okay. And what about 10 years in? We way underestimated it. And he said, okay, well, why? And it was the exact answer to the question you asked around the different players in the ecosystem need to be becoming aware of it. So for example, with the HSA's, first you had to build all this financial infrastructure with the banking partners. And it turns out just giving people the tax free money to invest is a little bit harder than it sounds.

我当时心想，哦，好吧。那过了十年呢？我们严重低估了这个问题。他说，好吧，为啥呢？答案其实就像你问的关于生态系统中不同角色需要逐渐认识到的问题一样。比如对于健康储蓄账户（HSA），首先你得和银行伙伴建立所有这些金融基础设施。事实证明，给人们提供免税投资资金并没有听起来那么简单。

And then after that, you had to get the carriers to say, okay, well, I'll make less money on high deductible plans. And I guess I'll offer them so I can have them as a companion to these HSA's. Well, then once you have the carriers create the plans, then, you know, it takes two, three years more. Then you have brokers who are getting paid commission on those plans saying, well, I'm going to get less commission on the high deductible plans. Why would I push that? And then finally, after you kind of get them on board, you need to have employers actually have it work out and make sure it works with their payroll systems, make sure that the employees can actually use it.

然后，在那之后，你需要让保险公司同意，决定在高免赔额计划上少赚一些钱，并且愿意提供这些计划作为健康储蓄账户（HSA）的配套产品。接下来，当保险公司制定这些计划后，还需要经过两到三年的时间。然后是那些从这些计划中获取佣金的经纪人，他们会想：“我在高免赔额计划上可以拿到的佣金更少，为什么我要推这种计划呢？”最终，当你说服他们同意后，你还需要确保雇主能够顺利实施这些计划，并确保其与工资系统兼容，从而保证员工真的可以使用这些计划。

And that because the buying cycle for these types of products is very annual around open enrollment, for that reason, it can really take multiple cycles before you start to hit that kind of minimum viable level of adoption and awareness. And so we're seeing a similar thing happen in ICRO. The market is starting to feel a little bit more educated and aware. And sure, you have to realign the incentives a little bit and communicate it in a way that everyone sees it as in their best interests, which takes a little bit of threading of the needle. But we believe we're at this kind of tipping point in the market where everyone kind of sees it as a, you know, it's here to stay. And it should be a core part of my strategy.

由于这些产品的购买周期与开放注册期密切相关，因此通常需要经过多个周期，才能达到基本的市场接受度和认知度。我们在ICRO市场也观察到了类似的情况。市场对这一产品已经开始感到更加了解和关注。当然，需要稍微调整激励机制，并以一种让每个人都认为符合他们自身利益的方式来进行沟通，这确实需要一些技巧。但我们相信，市场已经到达了一个临界点，大家普遍认为这是一个会长期存在的产品，并且应该成为核心策略的一部分。

What could go right and what could go wrong with respect to policy, either changes or things that, you know, are yet to come with respect to evolving this particular area of regulation. So kind of to our point earlier about having reached a certain level of market awareness, it's a little late kind of for the knife and the cradle. Like I think ICRO is here to stay. But there are certainly things that, you know, are coming that could affect the business model and the market overall. So one of those has to do with the inflation reduction acts subsidies during COVID and kind of the recovery period. The government created these enhanced subsidies for the individual market that allowed individuals to take advantage of more and more government help to purchase individual plans. And this had the effect of both increasing the total participation from around 11 to 21 or so million Americans.

关于政策方面可能会出现的积极和消极情况，尤其是在这个特定监管领域的变化或者即将到来的事情，我们可以探讨一下。如我们前面所说，现在市场的关注度已经达到了一定水平，对于策略调整我们可能为时已晚。我觉得ICRO已成常态。然而，确实有一些因素可能会影响商业模式和整体市场。其中一个因素与COVID期间通货膨胀减少法案的补贴有关。在疫情和经济复苏期间，政府为个人市场创造了增强型补贴，让个人可以利用更多的政府帮助来购买个体保险计划。这不仅增加了参与人数，还使美国参与者总数从大约1100万增至2100万左右。

And that stabilizing effect actually caused the prices to go down in the individual market, which is where we get plans from. We don't necessarily serve up plans from healthcare.gov. We get them directly from the carriers. They're called off exchange. It's a minor nuance, but they do mirror the on exchange market quite closely. And so when you look at what the effect might be of those subsidies expiring, if fewer people take advantage of individual plans because they get fewer subsidies, the overall risk pool might shrink and that might drive prices up, which could have ripple effects in the echro market. I will say from what we're talking with carriers, many of them for this coming year and the next year are already launching plans, really only focus for the echro market. And so we may see a decoupling of the on exchange and the off exchange markets quite soon. And then there are other potential kind of intriguing, more maybe like science fictiony iterations to the regulation that we think could come in future administrations, for example, allowing echro funds to be deposited, say an HSA accounts or to act more kind of like a turbocharged HSA where you can actually keep the funds with you from job to job, which would be super interesting.

翻译成中文： 这种稳定效应实际上导致个人市场的价格下降，而我们就是在这个市场上获得保险计划。我们不一定通过 healthcare.gov 提供计划，我们直接从保险公司获取计划，这些计划被称为“非交易所计划”（off exchange）。虽然这是个小区别，但这些计划与“交易所计划”（on exchange）非常相似。因此，当你考虑如果补贴到期可能产生的影响时，如果因为补贴减少而选择个人计划的人变少，那么整体风险池可能会缩小，进而导致价格上涨，这可能会在“echro市场”产生连锁反应。 根据我们与保险公司的沟通，其中许多公司已经计划在明年和后年推出仅专注于“echro市场”的计划。因此，我们可能很快会看到“交易所市场”和“非交易所市场”的脱钩。另外，未来可能会出现一些更有趣的、甚至像科幻小说一样的监管变化，比如允许将echro资金存入健康储蓄账户（HSA）中，或者它们变得更像增强版的HSA，你可以把资金在不同工作之间自由携带，这将非常有趣。

You're proposing a really interesting idea, which is more choice and more transparency in local markets for employers can bring prices down. What do you expect to happen at the local level? Will employers have more choice for the health insurance that they can buy? Will employees have more choice for the plans they can select? It's a great question. So there's really two things that happen if this market really takes off. The first kind of is the continued decrease in prices, increase in quality, which are a virtue of the risk pool growing.

你提出了一个非常有趣的想法，即在当地市场上增加选择和提高透明度，可以帮助降低价格。你预计在地方层面会发生什么？雇主在购买健康保险时会有更多选择吗？员工在选择计划时会有更多选择吗？这是个很好的问题。如果这个市场真的兴旺起来，会有两个主要变化。首先，由于风险池的扩大，价格会继续下降而质量则会上升。

So what happens in the individual market is not signa underwrites UJ and looks at the individual, they're looking at everybody who's buying individual plans in San Francisco and saying this is a pretty big risk pool. We can spread the risk over a large number of people and therefore offer better rates. So it's really the exact same mechanism of the group model. It's just applied to this kind of individual rails. And so the more people that participate in the Thatch model, like the Strands of Strath and the Thatch roof, grow stronger, better, et cetera. But when you play this forward 10, 20, 30 years, one of the things that gets us really excited is this idea that it will be a lot easier to start a health insurance company and to create a competitive product.

在个人市场中发生的情况是，保险公司并不是逐一审查每个投保人，而是把所有在旧金山购买个人保险计划的人看作一个较大的风险池。通过这种方式，他们可以将风险分摊到大量的人群中，从而提供更好的费率。这实际上和团体保险模式的机制完全相同，只不过应用在个人保险上。因此，参与这一模式的人越多，就像茅草屋顶的茅草一样，越结实、越好。然而，当你把这个趋势推向未来10、20、30年时，我们感到非常兴奋的是，将来可能会更容易创办一家健康保险公司，并且打造一个更具竞争力的产品。

And so when you think about today, all of the major employer sponsored health plans Blue Cross, United, Sigma, Ettna, they were all founded before the Internet and there has been no new companies formed in decades. And the reason for that is it's very, very expensive to start an employer health plan. You need basically a national network to be able to support employers because today, the workforce is super distributed. You can have a great, you know, Texas based insurer, but if you have one employee in Georgia, you can't sell the group plan because how do you cover that individual? And so if you have a large pool of people buying into this individual model, suddenly the insurgent health insurer can start up and target a local market for example in Houston where I grew up 40% of the population is Hispanic, many are, you know, speak Spanish as a first language.

因此，当你考虑到今天的情况时，所有主要的雇主赞助健康计划（如Blue Cross、United、Sigma、Ettna）都是在互联网出现之前成立的，并且已经有几十年没有新公司成立了。原因在于，创办一个雇主健康计划非常昂贵。你基本上需要一个全国性的网络来支持雇主，因为当今的员工非常分散。比如，你可能有一个很优秀的州内（例如德克萨斯州）的保险公司，但如果你的员工中有一个人在佐治亚州，你就无法销售团体保险计划，因为你无法为那个员工提供保障。因此，如果有大量的人群参与到这种个人模式中，新兴的健康保险公司就可以在本地市场启动，比如在休斯顿，我长大的地方，40%的人口是西班牙裔，许多人以西班牙语为母语。

There's no Spanish-speaking health insurance, there was with Spanish-speaking doctor networks. But in this future where you actually have people able to purchase individual coverage and pay for it through their employer, you can actually create these niche kind of differentiated products and you see more competition. When you look at the employer market, the main way they create market value is health care costs go up, they raise prices, they have a fixed margin, they're getting no more efficient and suddenly they're generating more profit and so the valuation goes up and so it's a really great business model. But if you had more competition, you'd actually have the opportunity to create value in the form of like increased efficiency, superior retention.

目前没有专门为西班牙语使用者提供的健康保险，不过曾经有以西班牙语医生为主的医疗网络。在未来，如果人们能够购买个人保险并通过雇主支付，那么就可以创建这些小众且有差异化的产品，市场竞争也会加大。在雇主市场上，市场价值的主要来源在于医疗费用的上升，他们会提高价格，保持固定的利润率，因此即使效率没有提高，也能获得更多的利润，于是企业估值上升，这确实是一个非常不错的商业模式。但是，如果市场竞争加剧，人们反而有机会通过提高效率和提升客户保留率来创造新的价值。

So imagine I'm an insurer and I can keep you, Jay, for the next 30 years. Well, suddenly, I may make investments today that pay off in 10 years knowing that I will reap the benefit of you being healthy over a much longer time horizon. And so in that future, we can actually harness the power of free market forces rather than use them to kind of hold America hostage in this somewhat of almost all-agophily-type environment. I love that. So free market dynamics and more insurance competition, tell us like one or two things that you guys can't wait to see consumers be able to do once this full vision of a gross market dynamics play out. I mean, a big area that we're focused on right now is how do we tell people, you know, we have 40% of the at-users are growing a balance month over month, meaning they're spending less on their health insurance than their employer provides for them.

想象一下，如果我是保险公司，并且能让你，Jay，继续投保未来的30年。那么，我可能会现在进行一些投资，这些投资在10年后会有回报，因为我知道在更长的时间内你保持健康会带来的好处。在这样的未来，我们可以运用自由市场的力量，而不是让它们像现在这样在某种程度上把美国经济“绑架”在一起。我对此很喜欢。所以你认为自由市场机制和更多的保险竞争将如何发挥作用？告诉我们一两个你们迫不及待想让消费者实现的目标，当这个成熟的市场动态完全展开时。例如，我们现在非常关注的一个领域是如何告知人们，目前有40%的用户每个月都在积累余额，这意味着他们在健康保险上的花费低于他们的雇主为他们提供的费用。

So they're growing these big balances and they're holding on to them. And we think the thing that's really cool is to tell people, hey, you've got $600 in your account. Have you seen the full-body MRI that you can use? Or a gray-o liquid biopsy? And like those kind of things are both valuable for people but also, you know, could save lives. And so a lot of people don't even know they exist telling them, you've got this money and here's somewhere that you can allocate it and get a better health care outcome really gets us excited. We may actually see this unbundling of health insurance where right now, major medical is the, covers the vast vast majority of health care costs. And if you look at a self-insured employer, the vast majority is going to major medical covering this health care costs and then they have a tiny little sliver for companies like Lyra Health and Mental Health Space or Fertility or MSK, et cetera.

他们正在积累这些高额余额，并且保留着这些资金。我们认为告诉人们“嘿，你的账户里有600美元”是一件非常酷的事情。你有没有考虑过可以体检的全身MRI或者灰色液体活检？这些项目对于个人来说都非常有价值，甚至可以拯救生命。很多人甚至不知道这些项目的存在，而告诉他们“你有这笔钱，可以在这里使用，以获得更好的医疗效果”是让我们激动不已的事情。我们或许会看到健康保险的解构，当前，主要的医疗保险覆盖了绝大部分的医疗费用。如果你看看自保的雇主，绝大多数的费用用于主要医疗以覆盖这些医疗费用，而像Lyra Health这样的公司在心理健康、辅助生育或骨骼肌肉系统（MSK）等领域只占很小的一部分。

One of the things we've seen is just a huge detriment to cost in the U.S. The way, you know, the pharmaceutical value chain works with PBMs and middlemen and a lot of the dollars extracted. And so wouldn't it be interesting if, you know what drug you want to buy? You can go to Mark Cuban's Cost of Life Drug Company. You get the silver plan and you allocate the rest of that drug. And so freeing up the medical budget to be allocated more efficiently in particular disease areas to prescriptions, super intriguing, and it might actually reshape how we think about the role of insurance as being more insurance than this, like, ticket to pay for everything.

我们观察到在美国，成本方面存在巨大问题。制药价值链的运作方式涉及PBM（药品福利管理）和中间商，大量资金被抽走。所以，如果你知道自己想买什么药，可以去马克·库班的生命药品公司。你可以选择“银计划”，然后把剩下的资金用于药物的采购。通过这种方式，可以更有效地分配医疗预算到特定疾病领域的处方药。这种方法非常有趣，它可能会重新塑造我们对于保险角色的理解，使保险更像是纯粹的保障，而不是支付一切费用的门票。

There are a lot of skeptics out there who ask the question, are consumers actually good shoppers of their own health care? And many argue that they're not. And I'm curious what you all make of that. I think, again, this comes back to the tooling problem, which is it's good for people to have choice. Everybody agrees on that. It's just if they don't have the proper tools to help them make those choices, then things get difficult. And to the tools question, I mean, analogy would be, okay, I want to book a flight to Fiji, all right? But, like, there's one number I can call, and I have to, you know, negotiate with kind of an unknown seller of the tickets, and they say, well, we can't tell you how much it costs until you land, and we can't tell you the airline.

有很多持怀疑态度的人会问：消费者真的能做好自己健康医疗的选择吗？很多人认为他们不能。我对大家的看法很好奇。我认为，这又回到了工具问题上。大家都同意，让人们有选择是好事。但如果他们没有合适的工具来帮助他们做出这些选择，那就会变得困难。关于工具的问题，可以用一个比喻来说明：比如说，我想订一张去斐济的机票，但我只能打一个电话，要和一个不知名的票务卖家商量。他们告诉我，直到我降落前，他们无法告知票价，也无法告知是哪家航空公司的航班。

But you can show up at, like, maybe this time, and maybe we'll leave it this time, maybe we'll leave before after, I don't know. And so you go, you show up on the plane, you arrive in Fiji, and you're like, okay, I made it to my destination, and they're like, well, congratulations, this'll be $10,000. You're like, wait a minute. I was expecting to pay this much. You just don't have the tools to do those things. Well, then, of course, they're not going to be a very good consumer. And so, this isn't all in Thatcher's purview.

但是你可以在这个时间点左右出现，也许我们这个时间离开，也许我们在之前或之后离开，我不确定。于是你登上飞机，抵达斐济，你觉得，好吧，我到达目的地了，然后他们说，恭喜你，这将花费你一万美元。你会说，等一下。我原本预计支付的金额不是这个。你只是没有工具去做这些事情。那么，当然，他们就不是一个很好的消费者。因此，这并不完全在撒切尔的掌控范围内。

I think there's amazing companies in the portfolio like Turquoise helping to make prices more transparent, and our hope is that as consumers have access to more dollars, more solutions will pop up to make it easier for them to spend those dollars. I love the optimistic future that we are all describing here, so here's to every employee having the opportunity to fetch at some point in their careers. Well, thanks so much for having us. Thanks. Yeah, that was awesome. Thanks for watching.

我认为投资组合中有一些很棒的公司，比如 Turquoise，它们正在帮助使价格更加透明。我们希望，随着消费者有更多的资金可支配，会有更多的解决方案出现，使他们更容易地消费这些资金。我喜欢我们所有人描绘的乐观未来，所以祝愿每位员工在其职业生涯中的某个时刻都有机会获得成功。非常感谢您邀请我们参加。谢谢。那真是太棒了。感谢观看。