Financial Results

Three startup “insurtechs” — Oscar Health Inc., Clover Health Investments Corp. and Alignment Healthcare Inc. — presented at the J.P. Morgan Health Care Conference in San Francisco last week, where they reiterated earlier projections that they expect to close 2024 in the black. Oscar and Clover expect to turn a profit in 2024, while Alignment says it will break even.

Oscar reiterated its promise to be profitable in 2024, and it teased entry into the Individual Coverage Health Reimbursement Arrangement (ICHRA) market. ICHRAs, which allow participating employers to reimburse employees for Affordable Care Act marketplace coverage at a fixed rate in lieu of purchasing a traditional group health plan, have also been identified as a target market by Centene Corp. in recent weeks.

A recent status report on the Medicare Advantage program presented by analysts with the Medicare Payment Advisory Commission led one MedPAC member to accuse leadership of producing a negative report for partisan political purposes. According to a MedPage Today writeup of a recent MedPAC public meeting, Brian Miller, M.D., of Johns Hopkins University said the report “appears to be slanted to arrive at a foregone conclusion in order to set up and provide political cover” before CMS issues its annual rate notice and “reads like attack journalism.” The report, which was presented on Jan. 12, showed that national market concentration in MA is nearing the Herfindahl-Hirschman Index (HHI) “highly concentrated” threshold, which the Dept. of Justice and the Federal Trade Commission use to review mergers. According to the presentation, the three largest MA insurers combined enroll 58% of MA members and in a typical market enroll roughly 80% of beneficiaries. That report also suggested that MA coding continues to generate excess payments relative to fee-for-service Medicare. Specifically, the MedPAC analysis of CMS enrollment and risk score files estimated that coding intensity will drive payments to MA organizations of $54 billion this year, up from $47 billion in 2023. “It is not lost on me that this discussion is occurring immediately prior to the CMS Medicare Advantage rate notice,” stated Miller, according to a transcript of the meeting. “The Chair has noted that he is in regular communication with CMS leadership. This gives the appearance that MedPAC as an independent and thoughtful policy organization is being hijacked for partisan political aims.” CMS’s annual preliminary rate notice is due out by Feb. 1.

The annual J.P. Morgan Health Care Conference in San Francisco, which took place from Jan. 8-11, has a well-earned reputation as the site of dealmaking. Last year, for example, rumors of CVS Health Corp.’s eventual deal to acquire primary care provider Oak Street began to emerge.

The 2024 edition proved to be less fruitful for dealmaking as far as managed care firms were concerned — never mind the $6.4 billion in deals announced at the start of the conference by Johnson & Johnson, Merck & Co. Inc. and Boston Scientific Corp.

Still, CVS and The Cigna Group each faced questions about the aftermath of megadeals, both real and imagined.

Although executing mergers and acquisitions (M&A) is an important part of health insurers’ growth toolkit, industry insiders tell AIS Health, a division of MMIT, that companies could face challenges completing deals in 2024 due to factors such as high interest rates and government intervention.

The Federal Trade Commission (FTC) and Department of Justice (DOJ) last month finalized updated merger guidelines for the first time since 2020. The FTC and DOJ noted the guidelines “are not themselves legally binding, but provide transparency into the Agencies’ decision-making process.”

Law firm Morgan Lewis wrote in a Dec. 21 brief that the FTC and DOJ are “dramatically expanding the number and type of transactions that the agencies will consider presumptively unlawful,” although the authors noted that the agencies have both “lost several merger cases in the last few years.”

UnitedHealth Group will sell its Brazilian subsidiary, Amil, the integrated managed care giant on Dec. 29 revealed in a filing with the Securities and Exchange Commission (SEC). Other publicly traded insurers have similarly divested international health insurance divisions in recent years after a notable trend of international expansion during the early 2010s.

UnitedHealth said in the SEC filing that its earnings guidance remains unchanged, and it added that the deal is expected to incur a $7 billion charge “which will be excluded from adjusted earnings, the majority of which is non-cash and due to the cumulative impact of foreign currency translation losses.”

Here’s how major health insurers’ stock performed in December 2023. UnitedHealth Group had the highest closing stock price among major commercial insurers as of December 29, 2023, at $526.47. Humana Inc. had the highest closing stock price among major Medicare insurers at $457.81.

While deal talks between The Cigna Group and Humana Inc. have reportedly fizzled, Cigna’s desire to sell its Medicare Advantage business is apparently still alive and well. Health Care Service Corp. and Elevance Health, Inc., are the two contenders for Cigna’s MA segment, which could fetch more than $3 billion, according to a report from Bloomberg, citing anonymous sources.

Industry observers say they aren’t surprised that Cigna is still trying to offload its MA book of business, even if doing so is no longer necessary to fend off antitrust scrutiny associated with a Cigna-Humana megamerger. What’s less clear, they say, is what Cigna’s growth strategy would then look like.

Bright Health Group, Inc. suffered another blow on Dec. 13, when the foundering startup insurer revealed that Molina Healthcare, Inc. will pay less than originally planned for Bright’s California Medicare Advantage business. Molina now plans to pay $425 million for the California business, instead of the originally announced $510 million — a development that could complicate the ongoing liquidation of several Bright subsidiaries and its Affordable Care Act risk adjustment repayment agreement with CMS.

According to a Molina press release from Dec. 18, “the purchase price for the transaction, net of certain tax benefits, is reduced from the previously announced $510 million to approximately $425 million, and now represents 23% of expected 2023 premium revenue of $1.8 billion.” Molina expects the deal, which it predicts will close “on or about January 1, 2024,” will add $1.00 per share “to new store embedded earnings” in the coming year.

While major Medicare Advantage insurers are bracing for potential revenue reductions stemming from upcoming changes to the risk adjustment model, three insurers presenting at their recent investor conferences appeared bullish on the prospect of continued growth in MA, and in particular, the sizable opportunity to serve people who are dually eligible for Medicare and Medicaid. According to a recent analysis from AIS’s Directory of Health Plans, roughly 5.6 million out of an estimated 13 million dual eligibles in the U.S. are enrolled in a Dual Eligible Special Needs Plan (D-SNP).

Although managed Medicaid and the exchanges remain its No. 1 and 2 revenue drivers, Centene Corp.’s MA business — which has a large concentration of D-SNP members — will be an “important growth driver for Centene long term,” CEO Sarah London told investors on Dec. 12.

Call it the blockbuster deal that never was. The Wall Street Journal reported on Dec. 10 that The Cigna Group abandoned merger talks with Humana Inc., ending a multiweek stir over a report from the same publication that the companies were discussing a deal that would have created a $140 billion megainsurer. With the dust now settling, analysts and industry observers are speculating about what comes next for the two firms — with some suggesting that Cigna may eventually wind up back at the negotiating table.

Neither Cigna nor Humana ever officially confirmed their reported deal discussions. But on the same day that the WSJ reported Cigna was abandoning its pursuit of Humana, Cigna said its board of directors had approved an additional $10 billion in share repurchases. Cigna CEO David Cordani also issued a telling statement hinting at what might have derailed the merger talks — per the WSJ, the firms couldn’t agree on financial terms — and addressing the company’s merger and acquisition (M&A) strategy.