Good morning, everyone. I'm Jennifer Gilligan, Senior Vice President of Finance and Investor Relations. Welcome to Centene's Virtual 2021 Financial Guidance and Investor Day. We are pleased to have an opportunity to update the investor community, and thank you for spending some time with us this morning. Earlier today, we issued a press release providing our full year 2021 guidance. This press release, as well as today's slide presentation, can be found on the investor relations page of centene.com. Additionally, please mark your calendars for our fourth quarter 2020 earnings call, scheduled for Tuesday, February 9th. Now, for the obligatory forward-looking statements. Please note that various remarks we make today regarding future expectations, plans, and prospects constitute forward-looking statements under U.S. securities laws.
Actual results may differ materially from those indicated by these statements as a result of various important factors, including those discussed in the slides you see in front of you, and the Risk Factors section of our most recently filed quarterly report and other SEC filings. Centene disclaims any obligation to update this forward-looking financial information in the future. Additionally, during this presentation, we will be discussing certain non-GAAP, that is generally accepted accounting principles, financial measures. A reconciliation of these measures with the most directly comparable GAAP measures can be found in today's slide presentation, which is available on our website at centene.com. I will now walk through some housekeeping items related to our virtual format, including instructions for Q&A. With the interest of our team's safety in mind, we will not convene as a large group today. As previously announced, some of today's content is pre-recorded.
Our question -and -answer sessions will be conducted live, and our management team will participate virtually. Questions can be submitted through the chat function on your screen. Your questions will only be visible to the Centene Investor Relations team. We will read aloud the questions, and the name and organization of the person submitting the questions. Questions can also be submitted via email. Feel free to send your questions to Libby Abelt at labelt@centene.com. After the virtual event concludes, we encourage investors and analysts to contact the Investor Relations team with any additional inquiries you may have. Finally, I'd like to highlight a few key themes that our management team will touch on during today's program. First, operational agility and how our organizational strength enabled Centene to successfully navigate 2020. Second, size and scale, and the way our diversified healthcare enterprise is well-positioned to pursue a multitude of growth opportunities.
Third, the acceleration of our technology strategy. With that, I would like to introduce Chairman, President, and Chief Executive Officer, Michael Neidorff. Michael?
Good morning. Thank you for joining us today. I hope this finds you, your family, and all your loved ones safe and healthy. Before we begin, we would like to share a video with you highlighting some of our key achievements for 2020.
[Presentation]
I often say that experience is the sum of experiences, but there is no experience that could have prepared us for 2020 and the magnitude of the impact that COVID-19 has had on our world. It has been a remarkable year, and one that has reinforced the importance of organizations like Centene that make a meaningful difference in people's lives. I am proud of what our team has accomplished, and that during these challenging times, Centene has delivered on our mission to provide high-quality healthcare to the most vulnerable populations. At Centene, we believe that purpose-driven organizations have the greatest longevity because they deliver tangible value to the people they serve. 2020 clearly represents a year where we delivered value to all stakeholders through a relentless focus on our mission.
Our dedication and management in a crisis allowed us to support members, providers, and state partners while creating significant value for our shareholders. This year, we have seen strong organic membership growth with approximately 25.5 million members by the end of 2020. In addition, the integration of WellCare has gone smoothly, and we remain on schedule with systems and health plan integration activities. We are pleased with the progress achieved to date, including delivering on synergies and transforming the growth profile of our Medicare business. Overall, for 2020, we expect to deliver revenue and adjusted diluted EPS growth of 48% and 13%, respectively. We have grown due to the pandemic. I want to be clear that we did not need the pandemic to grow, and we of course would have much preferred to do without it.
When adjusted for the impact of the pandemic-related growth, our 2020 revenue and adjusted diluted EPS growth would have been 43% and 8%, respectively. A tremendous accomplishment. Over the past 25 years, we have transformed Centene from a health insurer in three counties across two states to a $110 billion diversified international Health Care Enterprise with leadership positions across products and geographic markets. The diversification and scale of our business today are critical elements of our future long-term success, providing us with attractive opportunities for growth across markets and products, the ability to withstand and absorb volatility and near-term pressures in any specific business area, the financial strength to invest in our business, in new products, and in communities in which we operate, and opportunities to leverage our size and scale to control expenses and deliver margin expansion. We're not done.
Building on these strengths, we are transforming our organization and preparing Centene to continue to lead in an evolving healthcare industry and environment. As you know, our ambition is to transform Centene into a technology company that does healthcare. Achieving this will underpin and accelerate all of our other aspirations. We will provide a delightful experience for our members and providers. Develop innovative solutions to deliver better health outcomes and become an even more efficient organization, on top of our already highly disciplined approach. With that as the strategic backdrop, I think it is important that today you hear from Centene's senior leadership team about how we intend to deliver on those aspirations. Today, our technology team, including Sarah London, Brian Sivak, and Mark Brooks, as well as Darren Schulte, who recently joined us from Apixio, will talk in more detail about how we are accelerating our technology transformation.
They will also show you how we're enhancing our organizational structure to ensure innovative and technology-related companies are able to maintain their independence. Jon Dinesman and our Government Relations panel will discuss the promising political environment for Centene, and Brent Layton and our operations team will share updates on continued progress and growth opportunities across our products. Looking ahead to 2021, we continue to be conscious of our operating environment and factors that remain difficult to predict. These include the timing of vaccine distribution and fluctuations in utilization and membership, until people again seek healthcare as they did prior to the pandemic. Our goal has always been transparency, and I want to acknowledge where results have not met our expectations. While we are pleased with our performance in Medicare, we are expecting above-market growth.
We anticipate a more challenging performance at Marketplace next year, which has impacted our 2021 EPS guidance. Jeff will share additional details, but in a limited number of counties, we decided not to join our competitors in competing on price. As an experienced participant in Marketplace, the trend we are seeing is competitors entering the market on price alone with limited networks and withdrawing a year later. We will not participate in a price-related race to the bottom, and we are maintaining our strategy, which is successful. While we expect to see lower membership in 2021, we remain confident in our overall offerings. Again, Jeff and other members of the management team will outline the specifics related to 2021. Which I will say is that the core tenet of our strategy remains intact, and we expect to deliver meaningful revenue and growth in 2021 and beyond.
In closing, 2020 has been a year we will be glad to have behind us, but the challenges we faced allowed us to demonstrate our competencies and capabilities. We delivered for our shareholders while leaning into the factors that differentiate us. Our commitment to underserved populations, our extraordinary team, our focus on the whole person, and our deep relationships with providers, state, and community partners. We have built an organization that supports members and serves them where they are, whether it's through Medicaid, Medicare, Marketplace, or any other of our products. We will continue to find innovative solutions to improve the health of our communities. These are enduring values that will continue to guide our organization in the years ahead. With that, let me turn it over to Jeff and the team who will provide you financial details and take you through the rest of the agenda.
I will see you for a brief Q&A and at the end of the program. Thank you.
Thank you, Michael, and good morning. Thank you for joining us at our second virtual investor day. I hope everyone and their families are staying safe and healthy, and hopefully, this is the last virtual investor day we have to host. I have a lot to cover, so let me jump right in. Before I discuss the customary guidance details, let me set the stage for 2021. Over the last three years, we have solidified our leadership position in government-sponsored healthcare through geographic and product expansion and strategic acquisitions. This has led to a three-year compounded annual growth rate of 32% for total revenue and 25% for adjusted diluted earnings per share. We continue this evolution of the business with the completion of the WellCare acquisition in January of this year, adding additional scale in Medicare, pharmacy, and key Medicaid markets. The pandemic began.
We immediately refocused our efforts to support our employees, members, providers, and government partners as we progressed through the crisis. We moved 90% of our more than 70,000 employees to a work-from-home environment, all while not losing sight of our business objectives, including executing on our integration and synergy plan for the WellCare acquisition. In this pandemic, we have not sat still. We have strategically deployed capital to evolve and profitably grow the business in areas such as technology with the acquisition of Apixio, and specialty pharmacy with the acquisition of PANTHERx. We are confident in our ability to continue to make investments in new products, operational systems, and technologies that we expect will continue to deliver better health outcomes at lower costs for our customers and members, and will enable us to drive future growth and margin expansion.
Through this disciplined capital allocation, we expect to generate long-term growth rates in the mid -to -upper single digits on revenue and achieve double-digit growth in adjusted earnings per share. Where are we today? First, let me provide an update on 2020 and where we are through November's results. At the end of November, we had 25.4 million members, representing growth of approximately 1.6 million members since the crisis began. This is slightly higher than our previous expectations, which will drive incremental revenue growth this year. On the revenue front, we expect incremental retroactive adjustments in the fourth quarter of almost $290 million, bringing the new total for the year to approximately $790 million. This has been driven by the proposal of a risk corridor in our California market that is retroactive to July 1st, 2019, and growth in the rebate estimates in other markets due to lower medical costs.
As it relates to medical expense, through the first two months of the fourth quarter, we have experienced total medical costs that are below the historical average. This has been driven by lower non-inpatient services, including elective procedures and decreased prevalence of flu compared to historical periods. Our flu costs are down 95% from this time last year. The lower flu and non-inpatient expenses have been partially offset by higher COVID-19 treatment costs and the retroactive rate and risk adjustments from our state partners I previously mentioned. Based on the results through November, we continue to expect to achieve our 2020 adjusted earnings guidance that we provided on our third quarter earnings call. On to 2021.
Before I get into the details of 2021 guidance, let me remind everyone that consistent with our policy of not including acquisitions in the guidance until they close, we have not included PANTHERx in our guidance. We have excluded the operations, the cost to close the transaction, one-time integration costs, and the net effect of any additional debt to fund the acquisition. For 2021, we expect total revenues to be between $114 billion and $116 billion, and adjusted diluted earnings per share to be between $5 and $5.30. This represents total revenue growth of 4.1% year-over-year at the midpoints. Just a quick reminder that this is an addition to our more than 48% growth in total revenues this year.
Importantly, our guidance reflects 10.5% growth year-over-year in adjusted diluted earnings per share, where compared to the adjusted baseline of $4.66 we provided at the end of Q3. We expect our adjusted net income margin to increase to 2.79% at the midpoints for 2021. Digging into the details, year-over-year revenue growth is driven by several items, including a full year of the WellCare acquisition, an increase in member months due to the continued organic membership growth, primarily in Medicaid as a result of the pandemic, strong organic membership growth in our Medicare business, where we expect to increase our membership year-over-year in the mid-teens percentage, and the implementation of the North Carolina contract. This growth is partially offset by overall membership and our marketplace product decreasing year-over-year.
The elimination of the health insurer fee, the expected carve-out of pharmacy benefit management services in California and New York, and lower membership expectations in our PDP business. On the marketplace business, we expect our peak enrollment to decrease between 300,000 and 400,000 members and revenues to decrease by approximately $2 billion year-over-year, driven by membership reductions primarily in Florida. Overall, in our broad geographic footprint, we saw meaningful growth. However, several competitors in three highly populated counties in South Florida offered low price plans that have attracted members to their products. We have experienced price disruption in prior years with competition lowering price, attracting members, and experiencing financial losses, only to take large rate increases the following year or exit the market. We remain confident in our long-term strategy and price discipline to continue to grow and expand our marketplace product.
This pricing discipline continues to deliver expected pre-tax margins in the 5%-10% range for 2021. Additionally, based on our remaining membership mix, we expect there to be a benefit to the risk adjustment payment that has partially mitigated the earnings effect resulting from the lower revenue. We estimate the net effect of the membership decrease has lowered our adjusted earnings per share by $0.20-$0.25 for 2021. On our Medicaid product, we have assumed that redeterminations begin on May 1st. Based on that assumption, we expect our membership growth with respect to the pandemic to peak at the end of April 2021, with over 1.9 million new members, primarily in Medicaid and decreasing thereafter. With respect to rate increases, we expect our full year composite rate adjustment to be approximately 1.7%.
This is exclusive of the risk corridors and other revenue-sharing mechanisms instituted by several of our states in 2020. Our guidance includes approximately $400 million of revenue reductions associated with risk-sharing mechanisms instituted in 2020 that carry forward into 2021. For example, in Michigan, the state implemented a risk corridor program that ends September 30th, 2021. This result of this program produces an HBR of approximately 90%. This compares to our historical operating ratio in the high 80% range. The end result is that our HBR under the risk corridor program is higher than periods prior to the pandemic. Additionally, as a result of the pandemic, not all of our members were able to visit their doctor this year, which will lower our risk scores heading into 2021.
This effect will be much more prevalent in Medicare, where the risk adjustment is not relative to our competition like it is in Marketplace. Moving to HBR. For 2021, we expect our consolidated HBR to be between 86.6%-87.2%. The HBR for 2021 is primarily driven by the elimination of the health insurer fee and the effect of the ACA risk corridor recorded in 2020. We expect an adjusted selling general and administrative expense ratio to be in the range of 8.6%-9.1% in 2021, consistent with the 2020 expectations. The effect of leverage in the 2020 impact of the risk corridor and charitable foundation contribution is being offset by the elimination of the health insurer fee and the expected carve-outs on pharmacy, which carry a lower G&A ratio. The tax rate in 2021 is projected to be between 24.7%-26.7%.
This is substantially lower than 2020, primarily due to the elimination of the health insurer fee. I would like to highlight other metrics which are not part of our formal guidance. For other income and expense, investment and other income is expected to be between $310 million and $330 million, and interest expense is expected to be between $700 million and $720 million in 2021. We expect our investment income to continue to moderate as our long-term investments mature and are invested at lower rates. This has been predominantly offset by refinancing activities in 2020 that lower our overall cost of debt. Cash flow from operations are expected to be approximately 1.5x net earnings and adjusted EBITDA is to be between $5.3 billion and $5.5 billion.
We have a strong balance sheet and expect to deploy capital in 2021, primarily to fund growth, including statutory capital into our subsidiaries, continue to reduce our leverage, invest in our technology systems and infrastructure, and discipline M&A. We will be opportunistic with respect to share repurchases at certain stock price levels, but at this time have not included any repurchases in our guidance. Our capital expenditures are expected to be approximately $820 million for 2021. We expect the seasonality of our adjusted net earnings by quarter to be weighted 65% to the first half of the year. This is driven by the expectation of lower utilization in the first half of the year, driven by COVID, the traditional seasonality of the marketplace business, as well as higher member months in Medicaid early in the year, driven by the assumption of eligibility redeterminations beginning May 1st.
Overall, we have delivered strong performance in 2020, navigating what was an extraordinary year, achieved our synergy and financial accretion targets on the WellCare acquisition, and continued to deploy capital to grow the top and bottom line and transform the business for the future. Heading into 2021, we are well-positioned to continue to execute and deliver value for our shareholders, both in the near and long term. Thank you for your time and interest. Now I will turn it over to Kevin Counihan.
Thank you, Jeff. This morning, I will share more about the performance of our Marketplace product and how we are positioned for future success. As you know, Centene is an experienced leader in the healthcare Marketplace. As the product has grown and evolved, we have provided our members, providers, and state partners with consistent quality services that allow individuals access to high-quality care. In this year's open enrollment, we saw meaningful growth across our broad geographic footprint. As Jeff said, our overall membership for 2021 is below our expectations. This decrease is driven primarily by three counties in South Florida, where we saw aggressive pricing from new and existing carriers. As an experienced leader in Marketplace, we have seen this behavior before. We have seen carriers with aggressive pricing either quickly exit the market or raise rates.
In reflecting on this challenging year, we also believe the pandemic-related recession may have impacted our Marketplace enrollment in a variety of ways. First, segments of consumers are more price sensitive, making lower priced and bronze tiered plans more attractive. Secondly, pandemic-related enrollment may be migrating to Medicaid, where CMS has projected a material increase in enrollment. With the benefit of hindsight, this result is predictable. Looking ahead, there are things we will do differently. There are also things we will not do. We will not have a price-only strategy. We will not limit our provider networks so dramatically that we risk encouraging out-of-network utilization. We will not sacrifice quality for our members, providers, or state partners.
Instead, we will continue to offer networks and services that allow our members convenient access to quality care, and we will continue to be the source of consistency and stability for all of our stakeholders. This is how we have always run our business. Our strategy has always been to take a disciplined and consistent approach, and by doing so, we have grown to be an experienced leader in Marketplace. Looking ahead, we will maintain product leadership, and we will continue to grow. From a financial perspective, we are honoring our commitment to maintain margins, and as Jeff explained, we expect the membership decrease to be partially offset by a benefit to the risk adjustment payment. Our policy has always been transparency and to give you the facts as we see them today.
In this unique year, we are certainly disappointed with the outcome of open enrollment, but we are confident in our long-term strategy and our overall positioning. We will continue to maintain product leadership and to provide our members with access to consistent and quality healthcare. With that, I'll turn it back to Michael and Jeff for questions.
Thanks, Ralph. First, I want to emphasize that we're the national leader in this product and are confident in our strategy to continue to grow the product profitably and continue to be the national leader. Obviously, as you heard in our prepared remarks, we maintained our pricing discipline for 2021, while competitors in several counties in South Florida primarily lowered their prices. We did see more members, as Kevin mentioned, selecting the bronze product, which we think is the price sensitivity really driven by the pandemic. While we were disappointed with the overall outcome, it's not uncommon for competitors to be disruptive from year to year. We experienced this several years ago in our Texas market, where competition, some of these same competitors came in, they lowered their prices with narrow networks, ultimately incurred financial losses, but they took 40,000 of our members.
They exited the market in the subsequent year, and we got those 40,000 members back. It appears right now to us that some of the competition is really going after a member acquisition strategy and not really concerned about the profitability of the book. Another important point is related to risk adjustment. Based on what we know today about the members that have disenrolled from our products, we expect our risk adjustment payment, and remember, we're a net payer into the risk adjustment program. We expect our risk adjustment payment to decrease substantially, almost $800 million year-over-year. Somebody else is going to have to pick up that risk adjustment payment. Remember that the risk adjustment payment is based on the statewide average premium, not the premium that you bid.
If you are the low-price leader and you get a healthy selection of members, you're already at a disadvantage. Certainly, the pandemic has changed member behavior in the short term, but in the long term, we're confident in our product offering. We believe it provides more choices for members to receive their care. We think that we're going to be able to profitably grow the business on a going-forward basis. In short, I would call it a one-time event. Competitors can be disruptive. We believe the overall growth story for us and profitable growth is intact on a going-forward basis.
I'd just add, Jeff, three points. First, I learned a long time ago that when you're dealing with an entrenched competitor that has a high-quality product, the only way you can hope to try and gain market share is on price. I've also learned that those individuals over time learn that when you're losing on every unit, you don't make it up in volume. I think the third point here is that there was more price sensitivity this year than we've seen historically because of the pandemic and what people's income was and how they look at it. I think it was yesterday in the Journal, there was an article where retail sales are starting to fall off again because people are concerned about the pandemic and the availability of funds. We see some of this as very transitory.
We're going to stick to our strategy and are confident as it has prevailed all these years and catapulted us into a leadership position. We will maintain it.
Thank you, Michael and Jeff. Our next question is a follow-up, also from Ralph at Citi. You noted the 350,000 member decline on the exchanges. However, you entered a few new counties. Can you give us a sense of your adds there and some other geographies that are key?
Yeah. We picked up roughly 100,000 members in the expansion counties. I think the important point about the expansion counties you have to remember is some of those were in rural markets, right? It's not in the big population centers, but overall, that expansion, in our view, was very successful. Again, I think what we've targeted here is to say, the real challenges were in South Florida. In a lot of our other larger geographies, we actually grew membership. We're, again, confident in our overall strategy and product offering going forward.
Excellent. With that, we'll go to a question from Justin Lake at Wolfe Research. Can you please detail and give us some more information around the $400 million in state takebacks? Do you view this as a transitory dynamic, therefore moderating in 2022 and presenting an earnings tailwind? Do you view these mechanisms as being more permanent?
Thanks for the question, Justin. Appreciate that. The $400 million is really based on where we are today. I think long term, that does go away, obviously, when we get back into a more normalized, I would say medical cost environment. I think when you think about the COVID and the pandemic and how we forecasted that, we've provided a lot of information today, and what I would say is you can't take the $400 million in its isolation. We've assumed lower medical costs for the first half of the year. We have incremental members, because of the suspension of redetermination. You have the $400 million take back. We have, as you'll hear later in the program, we have some headwinds in the risk adjustment, predominantly in the Medicare Advantage business, really related to the pandemic. I think you have to take all that together in context.
Sitting here today, our view would be is you take all of these COVID effects, and for our guidance that we provided today, it's a net push. Hope that helps.
Thanks for that, Jeff. Our next question comes from Ricky Goldwasser at Morgan Stanley. Can you quantify the COVID-related headwinds incorporated into the 2021 guidance? Can you provide a bit more color on the competitive environment and specifically which geographies you're seeing that in?
I think maybe I've just quantified a lot of the COVID headwinds. I've talked about those. Obviously, the state take backs, there's a meaningful headwind, and I think other of our competitors have mentioned this in the RAPS in Medicare Advantage, specifically, where seniors didn't go to their doctor this year, there's a risk scoring that reduces your revenue next year. That's definitely a headwind. I think I've commented on those. The competition comment, I don't think there's anything that's changed with the competitive environment, specifically in the Medicaid side. Obviously, we've talked about the Marketplace business this morning and what we're seeing in South Florida. Generally, across the board, I think the environment is consistent with what we've seen in the past.
I want to just add for sake of argument, that one has to look at the scale and size we bring to the market. In a competitive environment with take backs and things we're worried about, we have the diversity and the scale to deal with it. We have the capability and technology and others to find ways to continue to reduce costs, as you'll see during the course of the day. We understand the competitive environment. The pandemic is something you have to go back to, what, 1918 to try and get any experience on. In those middle ages, it was very different. This is something new, and I think on balance, when you look at the performance this year, it's worked. We've been able to adjust to it very favorably.
Thank you both. The next question comes from Charles Rhyee at Cowen. Is the shift to a higher proportion of the Marketplace members going to bronze products versus silver reflective entirely of what's going on in the three Florida counties? Are you generally seeing price competition being highest in the silver category? Can you remind us if there is a margin difference between the metal tiers for Centene?
Yeah. Thanks for the question. I guess what I would say is in Florida, we talked about our shift in bronze. Kevin provided those aggregate numbers. What we saw from new sign-ups, these are new members that are signing up, we saw a higher mix of bronze. I think across our total profile, it was 26% of new enrollees are choosing a bronze product, it was substantially higher than that in Florida. I would call out Florida as a geography that had a higher bronze selection rate than, I guess, the rest of the country. As far as the margin is concerned, obviously, there's a lower premium there's a dollar difference. I would say there's not a lot of difference in the margin profile on a percentage basis, the dollars are obviously meaningful.
Thanks, Jeff. The next question comes from A.J. Rice at Credit Suisse. You indicated that your guidance does not include a contribution from PANTHERx. If it closes as anticipated, will it be accretive to 2021 EPS? Is there any way to size the first year contribution and long-term potential for the asset?
Yeah, this is Jeff. I'll cover this at a high level, and then later in the program you'll hear from Drew. In general, it's a magnitude question, really. Yeah, we think it's going to be beneficial to EPS, but it's not really going to drive the bottom line just because of the magnitude of the acquisition. I think on the top-line perspective, we're looking at close to $2 billion in total premium for 2021. More to come in the second part of the session here.
I think importantly, Drew also, I want to compliment him on it, that it just continues the diversification. We've always said one of our key strategies is to continue to diversify. I think when you hear about it, you'll see how he is diversifying in a very significant way.
Thank you both. The next question comes from Sarah James at Piper Sandler. Centene is set within the exchanges with an eye for folks that go on and off Medicaid. This year, that population is larger than ever before. How do you think about capturing that within the redeterminations group for the exchanges?
Maybe I'm confused about the question, how to capture the people. In general, what's happening now on the Medicaid side is people aren't moving off of Medicaid because they are not doing the redetermination efforts, right? That's what's growing the Medicaid business, is individuals are still continuing on Medicaid, and that's what we've seen, and that's what we're projecting all the way through May of this year, or next year, excuse me.
Yeah, I think maybe this is with an eye towards the future in terms of once redeterminations are turned on, thoughts around capturing those lives, as they become eligible perhaps for the exchanges.
Yeah, certainly that's been part of our strategy from day one. When we first entered the exchange market back in 2014, you remember, we were focusing on the lower half of the FPL, up to 250%. That's what the business was built on. That's what we focused on from day one. We've grown this business from zero members or 75,000 members in 2014 to where it is today to be the national leader. We're not done with that strategy. We're not discontinuing that strategy going forward. In our view, we're going to continue to capture as much of that as we can and drive profitable growth going forward.
We're also seeing an advantage where some people are finding that the Marketplace may be a better alternative to the COBRA when they lose their job or leave their company. That's where our broader network is really going to come into play, we believe, longer term.
Great. Thank you both for the color. This is a follow-up from Charles Rhyee at Cowen, relative to redeterminations. You are expecting Medicaid redeterminations to resume for May 1st. Can you talk about the start dates for some of your biggest states and when you expect those to resume?
I see what you're saying. You're saying that just because they're allowed to do redeterminations doesn't mean they will. I think that's the question.
That's right.
Yeah. Actually, I'll just give you the projections that we have. We think we're going to 1.9 million members by the end of April, and then we think that we'll start to decrease thereafter as certain states obviously do the eligibility checks. We think that's going to continue through the end of the year to where by December, we're roughly at 900,000 members that are still left in the pandemic-related growth. I'm not going to give you by state, but I'll give you the aggregate number.
I think also one has to wait and see what the new administration's going to do. There's a lot of talk right now in the pandemic relief fund, what funding the states get or don't get, and the fact they don't get it now doesn't mean that the new Biden administration won't give it to them. That's part of the, I don't want to call it choppy, but that's part of the things we have to deal with. That's where, once again, size and diversity will come into play.
Yeah. I agree with Michael on that. The May 1st assumption is really premised on extending the emergency one more time. That could prove to be a conservative assumption.
Thank you both. The next question comes from Josh Raskin at Nephron Research. Where is the new competition in the marketplace coming from? Is it the large national players, Blues and regionals, or the new startups?
We're seeing it mostly from, in most markets, from the startups. That's why you see them coming in out of markets from month to month based on what their funding and capability are. Some of them, there may be one or two that are in market, a Blues plan or something that will try and compete on price. On balance, we're seeing the startups do it, and the ones that have the weaker balance sheets, and we saw historically where they were using reinsurance to try and boost their balance sheet. It's a short-term play in our opinion.
Thank you, Michael. The next question comes from Scott Fidel, Stephens. Where within the 5%-10% margin range on the exchanges do you expect to fall in 2021? How much of a benefit do you expect from the risk adjustment payable change in exchanges in 2021?
Yeah, good question. As we've done historically, I'm not going to quote a specific number in the range. However, what I will tell you is because of the risk adjustment payment decreasing year-over-year, almost $800 million, it actually did increase the margin in the exchange business. One thing just to note is that individuals that don't have any healthcare cost codes, meaning somebody who doesn't go to the doctor at all during a year, those members aren't profitable. What's happened is that risk adjustment decreasing from roughly $800 million this year to roughly zero is meaningful.
Thanks, Jeff. The next question comes from Gary Taylor at JP Morgan. Can you comment on expected Medicare Advantage margins in 2021? Very strong enrollment growth, but you also mentioned risk score headwinds. Should 2022 MA margins improve materially?
I think you'll hear from Michael Polen later today about the solid growth that obviously we have going into 2021, and the premise of the WellCare transaction. We're obviously pleased with that growth and expect to continue to do that going forward. From the margin front, yes, I would say margins are a little bit lower than what we would traditionally expect, just because of the headwinds on the risk coding. We're really just going to have to see how 2021 plays out from the pandemic perspective and whether that goes away. Yes, long term, that is one of the key areas for us on margin expansion.
Great. Thank you, Jeff. The next question comes from A.J. Rice at Credit Suisse. The company is adjusting its long-term revenue growth target from double-digit to mid-to-upper single-digit. Is this simply a function of law of large numbers, or is it a reflection of moderating growth in any of your markets, such as Marketplace?
Yeah, I'll start and let Jeff pick up on it. Obviously, as the denominator gets bigger and bigger, the percentage of growth will be affected. I remind people that we're basically talking about organic growth, as we don't include any acquisitions you heard earlier until we know they are, in fact, there. I would say, and we're looking at international and other things with this growth. Right now, based on what we know in the large denominator, a high single digits seems to be a reasonable place to start.
Yeah. The only other thing I would add to Michael Neidorff's commentary is, you have to remember that 70% of our revenue is still Medicaid related. In the Medicaid business, you don't get 5% to 6% to 7% premium inflation every year, right? You've seen our rate adjustment for this year. I think it's both reflecting the size and scale of the denominator as well as the mixed business.
I think, Jeff, when Brent talks about his growth and shows the growth, I think people will get some reassurance that we are still very much a growth company.
Absolutely.
Thank you both. The next question comes from Stephen Tanal at SVB Leerink. The midpoint of 2021 guidance represents a CAGR of 8%, even with the WellCare deal included. How are you guys thinking about standalone Centene and how that would have grown? What gets you comfortable with reiterating long-term guidance of double-digit EPS growth for the combined company going forward? What does that algorithm look like today?
Jeff can start, but I want to remind everyone that from the point in time when we complete the acquisition, we don't talk about legacy one versus the other. It's really now all 100% Centene. We've taken that approach back to the inception. Jeff, you want to add something?
Yeah. I think as far as the path to double-digit margin growth, as I sit here today, obviously, we just talked about Medicare. There's obviously margin opportunity there. The other piece is, we've grown substantially, as you saw on my slide today. We've grown substantially over the last five years. We really haven't realized the full benefit of that scale. You'll hear later today from our technology team about what they're doing. Ultimately, that is going to drive cost efficiencies from a going forward perspective. Additionally, just to remind everybody on the WellCare front, $500 million net year two synergies, which would be 2021, $700 million run rate synergies that we're targeting for. A lot of that work to get to that $500 million-$700 million is actually happening in 2021.
As I look forward, and look at the margin profile, I think there's plenty of opportunity to continue the double-digit growth rate on the bottom line. Today, you noticed I mentioned share repurchases were going to be opportunistic. That's something new for us as well that would obviously trend us in that right direction.
Yeah, Jeff, when we don't chase price on Marketplace and things like that becomes kind of another good indicator that we continue, as we've said we will be, focused on margins.
Absolutely.
Thank you both. Along the same lines, this question comes from Matthew Borsch at BMO. On the topic of intensity of competition, how does Centene see that evolving in Medicare Advantage, in PDP, and in Medicaid, as well as the group commercial or former Health Net business?
Yeah. There's going to be competition. Obviously, it's competition, and we continue to do well. I think, once again, the one area that we've seen where people can say it didn't serve us well was in the Marketplace. That was price. It's during the time of a pandemic. I also remind what Jeff said, we're going to improve our risk adjustment by $800 million. It's a matter of looking at the total picture. I believe that this company has the focus and capabilities to be more than competitively generous as we've demonstrated against large and small competitors. We're just not going to follow prices to the bottom.
Very good. The next question comes from Kevin Fischbeck at Bank of America. You're excluding about $200 million of transaction expense. Is this related to deals already announced, or does this assume some meaningful additional activity?
That would be related to deals that are already announced. I mentioned the platform consolidation, there's overlap work that heads into 2021, obviously with Apixio and PANTHERx Rare, those are the two that are in there. There's transaction costs there.
Excellent. Well, with that, we're going to wrap up the Q&A session and move to some additional content from our presenters. There'll be an additional Q&A session led by our operational leaders just after these presentations.
Good morning. My name is Sarah London. I'm thrilled to be with you on what marks the close of my first 90 days of employment with Centene. In recent years, you've heard about Centene's ambition to become a technology company that does healthcare. That vision is why I'm here. We are at a unique inflection point in the digital evolution of healthcare, and transformation in this industry is going to require leadership. With 25 million members in 50 states, representing some of our country's most underserved and complex populations, Centene is steward to a significant and unique set of data and insights.
The opportunity to leverage this data and Centene's platform, not just to shape, but to lead the digital transformation of healthcare, and to create an experience that delights our members and providers, was too great an opportunity to pass up. I'm joined today by Mark Brooks, our CIO, Brian Sivak, our SVP of Technology, Modernization, and Innovation, and Darren Schulte, our new President of Advanced Technology. As a team, we have been designing the roadmap to accelerate Centene's progress against our technology mandate. This morning, we'd like to share some of the key themes that will guide our work in the coming year. First, given the benefit of relatively fresh eyes, I thought it might be helpful if I offered my perspective on the work Centene has accomplished to date. We all know that Centene has grown rapidly in the last five years.
What that means from a technology perspective is that we have equally rapidly inherited and needed to consolidate a full complement of legacy technology platforms. It is a testament to Mark Brooks' leadership and the focused execution of Brandy Burkhalter's operational teams just how much integration work has been accomplished during that time. In the last two years alone, the company has significantly streamlined our technology footprint in the areas of HR, finance, customer service, claims processing, care management, and more. We've also successfully integrated the data from our acquisitions into a unified infrastructure supporting enterprise-wide reporting and analytics. While these are must-do items, they are by no means easy to do. I fully expect we will build on this disciplined approach to integration as a key differentiator going forward. I've also found a thoughtful approach to the technology pipeline in light of a rapidly changing landscape.
The business and technology teams have prioritized critical foundational capabilities like data, which you will all come to find is one of my most favorite topics. They've capitalized on technology tailwinds and aggressively advanced us to a cloud disposition. They've built strong teams who are eager to innovate. You'll hear more about this from Mark and Brian. I believe that we are now in a position to lead. In addition to my role coordinating technology strategy, I lead our Health Care Enterprises group. In light of that, I should note that the organization also recognizes partnering as an important strategy to take advantage of startup innovation and focus factories around some of these technology problems.
As many of you know, we have in the past leveraged Health Care Enterprises as an incubation destination for early and mid-stage companies pursuing technology or clinical models we feel will be central to our strategy. Our goal has always been to ensure that Health Care Enterprises companies can continue to serve both Centene and their market customers with no cross-contamination. Going forward, we will reinforce the independence of Health Care Enterprises companies, and we intend to pursue a pipeline of partners that advance our internal technology agenda and our desire to grow and expand the markets and mission-aligned partners we serve. A great example of this is Apixio, the acquisition of which we finalized just last week. Apixio will join the Health Care Enterprises group and continue to operate and innovate independently.
We are excited about partnering with them to expand the applications of advanced, highly calibrated healthcare NLP to make our business and our interactions with members and providers more seamless. On that note, I'm going to turn it over to Darren Schulte, formerly CEO of Apixio and now Centene's President of Advanced Technology, to share his perspective on the partnership between Apixio and Centene and to give you a glimpse into how he's thinking about our advanced technology pipeline. Darren?
Good morning. My name is Darren Schulte. I'm very excited to lead the Advanced Technology team at Centene. First, an introduction to my former company, Apixio. Apixio developed and refined a proprietary AI platform over the past 10 years to render computable data from clinical notes, administrative forms, and other healthcare text. Text in these notes contains 80% or more of the relevant information about individual healthcare not contained in claims or other administrative data. Apixio combines insights it renders from text with structured data to create a comprehensive health profile known as a phenotype. These health profiles are made available to applications for presentation and analysis. Now that Apixio operates independently within the Centene Health Care Enterprises group, we can leverage Apixio's AI capabilities and data science to advance our advanced technology efforts and enrich Centene applications and services.
As such, we can create a better outcome for our members, less burden for our providers, and more automation and efficiency for our business. Over the next 10 years, we envision the practice of healthcare to meaningfully change. Technology will play a central role in healthcare, including the diagnosis, management, and treatment of disease. Drugs and therapies will be developed and manufactured specifically for each person, given their unique genome, proteome, and metabolism, and care will be provided virtually and in an increasingly non-invasive manner. In this new world, Centene will be a trusted convener and partner in health, and a leader in the discovery and use of novel approaches to bring about individual wellbeing throughout life. We intend for Centene experience to be unique for each person. Benefits will be precisely tailored to achieve the desired wellbeing.
There'll be a lack of administrative friction, operational and payment activities largely automated in the background. We believe that future innovation in Centene is catalyzed in the creation of a healthcare learning and discovery platform. Our membership of more than 25 million individuals and growing is diverse in a myriad of ways, and their data provides unique insights with which to significantly advance healthcare. With rapid data collection analysis and experimentation across our membership, we can better select and tailor our use of technologies and services to create optimal health as defined by an individual at each phase of their life. With our technology platform and our data foundation, we can learn what works, in whom, when, and under what circumstances, and we can then tailor benefits, care, and delivery for each member. We can guide individuals to participate fully in their care and make better, more informed choices.
To bring about this innovation, our advanced technology team will be comprised of world-class data scientists, engineers, clinicians, designers, bioethicists, and behavioral economists. Research and development will not just be confined to just one team. We will infuse innovation and experimentation into the entire organization so that these behaviors become integral to our company's DNA. It is through these collective efforts that we will bring about a unique, personalized digital healthcare experience for each member, and we will learn from millions to optimally care for one. A technology company that does healthcare. Now I have the pleasure of turning this over to my colleague, Mark Brooks.
Thank you, Darren. We're happy to have you as part of the team. Thank you, Sarah, for acknowledging the success Centene Technologies has experienced in the last year. This morning, I want to share with you a little bit more about how we are implementing leading-edge solutions that enable real-time results. As Sarah mentioned, for Centene, the ability to integrate acquired platforms quickly has become a core competency, which we often refer to as our integration engine. One example she didn't mention is how our infrastructure team leveraged this model to develop a hybrid data center cloud footprint in record time. This is already leading to great results. Our core technology environment is not only able to manage meaningful integration of acquired assets, it enables rapid implementation of built and bought solutions.
This capability is essential, particularly as new solutions from our advanced technology group, digital product office, and Health Care Enterprises organization are introduced into Centene as a platform, our technology ecosystem. What's really interesting is it's had this ability for some time. However, with our new partnerships and structure in place, it will only move faster. All of these efforts combined have resulted in Centene's environment becoming optimally responsive to growth and innovation. One of the best examples of a rapidly developed solution built upon our technology core is TruCare Cloud. This next-generation application, created in partnership with Centene Population Health, has been swiftly deployed throughout the last 18 months, delivering new utilization management and care management capabilities to our teams. An industry-best solution, TruCare Cloud puts the health of members first by identifying and remediating care gaps.
By leveraging real-time data and alerts, it empowers cross-functional care teams to engage and prevent escalating and potentially critical health issues. TruCare Cloud shares each member's individual story over time, including care plan progress, follow-through for clinical appointments, and interactions with, for example, behavioral health and digital care management providers. It uses data to ensure that each member has the knowledge they need to achieve an optimal clinical outcome. This level of sophistication is possible because TruCare Cloud was born in the cloud, boasting complex feature integration built using human-centered design. Its technology speeds workflow, enables omni-channel communication, facilitates multi-site care delivery, and eloquently leverages powerful AI capabilities to automate assignments and scheduling. As a key support system for care teams, its functionality is boosted by a holistic view of the member's health, including real-time biometrics, lab results, medication lists, and clinical claims visits.
Our approach to rapidly developing solutions upon our technology core does not stop with TruCare Cloud. By using the same approach for call center, membership, and claim systems, we were able to bring innovative technologies into the hands of end users faster than ever before. For example, our newest claims AI pilot has reduced processing time for pended claims from an average of 18 minutes to an astounding 3.5 seconds. We have no plans to stop there. More innovative technologies will be delivered in 2021 to best meet the needs of Centene's members, providers, and employees across the globe. Centene Technologies is humbled to be part of each member's care experience, even from afar. Through close partnerships with our business colleagues, we find new and innovative ways to leverage technology to do what Centene has always done, care for the most in need.
By implementing the right technology in the right place at the right time, we simply do just that, but better, smarter, and faster. Thank you for having me today, and now I'm going to turn it over to Brian.
Thanks, Mark. When we think about what it means to become a technology company that does healthcare, one of the areas we will be focused on is restructuring our digital delivery capabilities in a product-focused operating model. This will open up a number of opportunities for us, including a tighter alignment between our strategic and technology priorities, an increase in our ability to quickly and rapidly adopt digital capabilities across our local and scale model, and the opportunity to easily take advantage of cutting-edge innovations in healthcare and other industries. We will be focused on streamlining our day-to-day operations, whether internal or those that touch and enable our key stakeholders. Our technology agenda will ruthlessly automate administrative functions in the same way that other industries, like financial services, have moved from manual paper-based processes to an infrastructure for digital transactions.
We will also be focused on building novel experiences that reimagine what it means to be a healthcare company in the next decade. It's always important to remember that technology without users is nothing more than a bunch of ones and zeros. To this end, we're going to emphasize not the value of the technology itself, but the value of the impact the technology can have. Nowhere is this more important than in transforming our member and provider experiences. As an example, let's talk for a minute about our provider partners. As you all know, the industry is littered with failed attempts to bridge the payer-provider technology chasm. It represents a massive opportunity, but to be honest, there are very few examples of it working well. However, one of many plans innovating right here at Centene is our Buckeye Health Plan in Ohio.
The team at Buckeye rightly believes that their role is to enable and empower their provider partners along the journey to value-based care. They think in terms of risk-sharing, not risk-shifting. In other words, we're all in this together to create the best outcomes for our members. How do they do this? Well, first, Buckeye recognizes the greatest way they can empower their providers is with data. To this end, they have contracted directly with the state's Health Information Exchanges to pull current member-level clinical data that they then integrate with their claims data. This complete data set is hugely valuable to both Buckeye and to their provider partners as it allows the plan to close quality gaps through data without bothering providers to pull charts.
In the last two years, they've ingested data from 18,000 providers across the state, and they've been able to close thousands of care gaps for key areas of focus, such as BMI, nutrition counseling for children and adults, and diabetes care. In addition, Buckeye sends that integrated data set, along with analytic enrichments, back to their providers, who can then use that data in their EMR or in their respective population health tools. We send it where they want it. In fact, Buckeye is so bullish on the power of this data that they offer financial incentives for providers to connect to and use the HIEs. Starting in 2021, they plan to expand incentives with the goal of making this data available to 100% of their providers in value-based arrangements.
In addition to a focus on data, Buckeye recognizes that provider groups are already swimming in their own complicated technology ecosystem. Instead of trying to add yet another requirement to the mix, Buckeye has established a technology enablement fund through which they offer grants to providers for tools that help them leverage the value-based data and transform their workflows to succeed under these advanced payment models. As a result of this approach, 100% of Buckeye's providers are now eligible for value-based arrangements, with 75% and growing participating in the programs, and 60% of their Medicaid reimbursement is tied to value-based performance contracted providers. Most importantly, thanks to the great work of these provider partners, the plan is a leader in quality outcomes. None of this is possible without a world-class team to execute on an agenda.
As you all know, this summer we concluded an agreement with the state of North Carolina, Mecklenburg County, and the city of Charlotte to construct our new East Coast headquarters. This is a massive project, which when it's fully realized, is going to create upwards of 6,000 high-paying jobs in the Charlotte area. Over the course of the next few years, we're going to be hiring folks across Centene's diverse business operations. Most critically, we are focused on creating a world-class technology hub. We're going to hire technologists with a wide variety of skill sets, including front and back-end developers working with the latest cutting-edge tools, top talent in machine learning and artificial intelligence, human-centered design specialists, and product management specialists, all focused on delivering novel technology and powering our next phase of growth. We also take our local connections seriously.
We will be partnering with organizations such as the Charlotte Regional Business Alliance and LaunchCode, a nonprofit that offers tech education to people with non-traditional backgrounds and helps them find fulfilling new careers. We've worked with them for years in St. Louis, and we're thrilled to expand our partnership to our new location. We're thrilled about our progress on our new West Coast headquarters, and once we return to a more normal existence and the construction is complete, I can't wait to host you all there at a future Investor Day. Thanks very much, and back to you, Sarah.
Thanks, Brian and team. Hopefully this helped provide a bit more insight into the exciting mission this group is tackling together. Ultimately, as we work to assemble this next generation technology ecosystem, we believe it is critical that we keep our end goal in mind. Yes, we want to be a technology company that does healthcare. What does that mean? It means being able to grow and integrate seamlessly. It means being able to streamline and automate our operations. Most importantly, it means creating an unparalleled and empowering experience for our members and providers. We must integrate, we must automate, and we must delight. Thank you. I'll now turn it over to Shannon Bagley, our EVP of Human Resources, to provide an update on our COVID safety protocols and return to work plans.
Good morning. My name is Shannon Bagley, and I'm pleased to be with you. As you know, our employees' health and safety is our highest priority, and we remain steadfast in our commitment to our workforce. From the early onset of COVID-19, Centene leveraged its modern infrastructure and its agility to enable prompt decision-making and swift execution of critical actions to ensure continued delivery of services to our members. While we operate well in this remote environment, as a growing organization, we are looking forward to the time when we will once again be able to engage in ongoing collaboration amongst our colleagues through in-person interactions and shared experiences. This morning, I'll share with you our comprehensive plans to keep our employees healthy and safe, including expanded employee benefits and resources, flexible work arrangements, and new facility protocols.
My overview builds upon the dialogue you've heard throughout the day, reinforcing our active leadership with our communities, our state partners, providers, and members. As you may recall, Centene transitioned 90% of our workforce to a work from home environment in less than a week, and this arrangement continues today. Several new employee benefits and resources which were established in 2020 will continue into 2021. Employees will receive 10 days of additional emergency paid sick leave, and we will continue to waive prior authorization and cost-sharing for COVID-19 related employee care. Employees will have access to our medical volunteer benefit, which provides up to three months of paid volunteer time off. We will continue to offer employee wellbeing resources, our highly trained COVID concierge and contact tracing team will be available for all COVID related questions.
We also plan to provide employees with more flexible arrangements as we prepare to transition into an office setting later in 2021. Employee engagement is critical in our extended remote setting. In recent listening surveys, our employee engagement results exceed top quartile Fortune 100 benchmarks. Centene has offices across the globe, and we decided early in the planning process that as we begin to return to the office, we would do so in a conservative phased approach and in line with CDC recommendations, medical experts, and local guidelines. Earlier this year, we announced that our return to office plans would be delayed until after April first of 2021 for employees who regularly work in an office setting.
As there is not a one-size-fits-all solution, we established a return to office framework for our business unit leaders, enabling consistency in returning to the office, both in timing and approach across all of our offices. When we do begin to return to the office, we will do so in a multiple phased approach spread over a series of months. In general, our plans consist of three phases. Phase I includes the return of 10%-15% of the workforce. Approximately 30 days after phase I, we'll begin phase II, allowing for up to 35% capacity. In phase III, we will allow for approximately 50% capacity. We anticipate being at half capacity throughout much of 2021. To ensure healthy interactions, alternating work from home and work from the office schedules will be provided for our workforce.
Over the past months, we've prepared our offices to reduce the spread of COVID-19 and have communicated new office guidelines to employees for both transparency and safety. A new daily self-screening texting program will be utilized to reinforce symptom checking and to support decision-making. In select locations, additional testing options will be available for the workforce. We will also explore the possibility of supporting local communities with vaccination distribution. All of our offices have been updated with new instructional signage to enable social distancing. While most of our cubes are 6 ft by 6 ft or larger in dimension already, we invested more than $20 million to retrofit our cubes with acrylic screens for additional protection from the spread of respiratory droplets.
In addition to signage and new screens, we've installed thermal temperature scanners for our high volume offices and have developed a dedicated contact tracing team for positive diagnosis. While we've laid the groundwork for new workforce and facility protocols, we are also designing for the future. We are leading the way in building the post-pandemic workplace of the future, partnering with human-centered design experts to enhance our facility designs, beginning with our Charlotte, North Carolina campus. Overall, while there remains uncertainty in terms of how the pandemic will evolve, we are fully prepared to provide a safe environment for our employees when the timing is right. In addition, we will apply what we've learned during this time to enhance the working environment for all of our employees as we continue to evolve and build a thriving workplace for our workforce, both today and in the future.
Wow. It's been six months since we were last together, we're still virtual. Hopefully, the next time we get together, it will be in person. Earlier, you had the opportunity to hear from Michael on Centene's strategy of a local approach and a razor-sharp focus on governmental healthcare. This strategy and philosophy has served us well from the beginnings all the way back to 1984 when we started in Wisconsin. I'd like to show you a couple of examples of Centene's growth trends throughout the years. Let's start with 2004, 20 years after Centene began. In this slide, you begin to see modest growth at Centene, entering Texas and Ohio through acquisition, and Indiana through application. This next map looks very different. It shows Centene today. Currently, we're in all 50 states.
In 2021, this will include 30 states for Medicaid Managed Care, 33 for Medicare Advantage, and 22 for Marketplace, and we continue to grow and innovate. This groundbreaking growth started with a bid back in 2005 in Georgia, which was the first state to go from fee-for-service to mandatory Medicaid Managed Care statewide, essentially overnight. The success of Georgia's transition created a domino effect that moved Medicaid Managed Care forward, making statewide RFPs commonplace. During this time, Centene continues to be at the forefront of rapid growth and adoption of managed care. We also diversified through our Exchange and Medicare Advantage businesses. Today, both state and federal governments have seen the benefits of our programs, including taxpayer savings and, most importantly, quality healthcare outcomes. Our strategy of geographic and product diversification has led us to where we're at today.
We see great opportunity in expanding and adding new products in our current states, entering new states, and creating approaches that are responsive to our customers' needs. Now, I'd like to take a moment to show you how this strategy's led to a very specific state growth. One example is in the state of Illinois. We entered the state in 2011 with a small program in the collar counties around Chicago for the aged, blind, and disabled population. Over the years, several more Medicaid aid categories were added to Medicaid Managed Care, including long-term services supports and even foster care, and we also introduced our Ambetter product into the market. nine years later, we've gone from 16,000 members to over 900,000 members. Now, that's growth.
This growth was not only from product diversification but also geographic expansion, growing from the greater Chicago area to eventually serving members statewide. Clearly, geographic and product diversification has fueled our growth. There is a third element to our strategy, a focus on governmental healthcare. As the chief business development officer, I realize that you have to focus on your customer. We've always made that a priority. As you can see here, we have grown under every presidential administration because we work hard to be responsive to the needs of our customers, both state and federal. Make no mistake, this is Centene's moment. We see this as another groundbreaking opportunity. Our size, scale, and experience leaves us well-positioned for continued growth and diversification. With a new presidential administration entering, the opportunities are only growing. Here, you can see our levers for growth.
As I've discussed, our goal remains to enter new markets and maximize our current operation through product offerings and geographic expansion. We continue to see great growth opportunity in Medicaid with new and existing markets. We're a more recent entrant into Medicare Advantage, but the strength of our product through the WellCare acquisition is rapidly accelerating our growth. We will continue to be a leader in the marketplace product and look forward to seeing how the new administration strengthens the ACA. Opportunities in federal services continue to grow, which I'll talk about here in a moment. We continue to believe in our healthcare enterprise business and also our technology solutions, and I look forward to sharing about our international growth in the future as we continue to make great progress. Now, I wanted to give you a glimpse in some of our current opportunities.
With growth comes re-procurements, such as Ohio, where we submitted an RFP last month. We continue to pursue new business opportunity in states that are transitioning from fee-for-service to Medicaid managed care, such as Oklahoma, and I know you've all heard me speak to North Carolina in the past, and we look forward to serving their Medicaid population when their program begins in July. The state has already issued a second RFP that they call their Tailored Plans, which includes services for behavioral health, intellectual and developmental disabilities, and traumatic brain injury populations. While there are great opportunities to grow in Medicaid, there is also an opportunity to grow our federal service offerings. As you probably know, Centene currently manages TRICARE West. I'm excited to announce today that starting on January 1st, we will begin to administer the TRICARE (T-2017) pilot program in the Denver area.
This pilot program will bring together administrative, medical, and outcome-based risk. This new approach, focused on quality and care management, will prepare us for an even larger opportunity for the TRICARE (T-5) bid expected in the near future. Now, there is no doubt that 2020 has presented everyone with their share of challenges, and our relationship with our governmental partners has never been more crucial than during the pandemic. We continue to find ways to offer support to all of our stakeholders as we navigate the COVID crisis. We've also maintained our focus on being a strong partner to our providers. Ron gave you one example in Ohio, where we continue to find ways to support and partner with our providers.
This has happened across all of our markets, where we're working every day to eliminate administrative hassle and develop and implement payment models that produce quality outcomes, pay our providers quickly and correctly, helping us to catapult to be the leader in value-based purchasing. This is the same slide that I showed you back in June. It remains true today that despite COVID and regardless of leadership in Washington, Centene is constantly evolving. We have assembled the skills and people needed to continue our drive toward growth, profitability, and success. Our size and scale, strong balance sheet, partnership with providers, history and experience, leaves us well-positioned to continue to grow for many years to come. In closing, I have been fortunate enough to work for Centene for nearly two decades, focused on growth both domestically and internationally.
The company has recently added a few new responsibilities to my list, but we are, and have always been, a growth company. To be a growth company, you must be focused on the customer. That customer could be state or federal governments, or that customer could be our providers or our members, be they Medicaid, Medicare, insured, or TRICARE. We will ensure our approach continues, where quality and value are paramount to our daily mission. As we look to 2021 and beyond, our position for long-term growth and profitability is better than ever. We look forward to continuing to look at all addressable healthcare markets. We truly believe this is Centene's moment, and yes, the best is yet to come.
Thank you. I'm Dave Thomas, Centene's Executive Vice President for Markets. I'm happy to have the opportunity to talk to you about my division. As Michael and Jeff said earlier, 2020 was a very successful year for the Markets Division. Despite many challenges, we have worked closely with our providers and regulators to manage through the COVID pandemic and effectively support our members. As a result, we have been able to bring on 1.6 million new Medicaid members while keeping our WellCare integration activities on track. For 2021, we expect continued growth and a slow return to normality and improved operational efficiency. The Markets Division currently serves 17.1 million members across all product lines, making Centene the leading provider of government programs healthcare in the U.S.
We now have 13.4 million Medicaid members across 30 states, 1 million Medicare members across 31 states, and 2.2 million Marketplace members across 21 states. In all, our membership has increased 50% year-over-year. This is primarily a combination of WellCare integration and COVID-related growth, with most of the COVID-related growth due to the suspension of member redeterminations. There were many highlights for the division this year. These include the implementation of Illinois Youth in Care in two phases, the first in February and the second in September, the successful integration of WellCare's New York membership into Fidelis on June 1st, the successful completion of our acquisition of NextLevel Health in July, the implementation of Medicaid expansion in Nebraska on October 1st, and the successful reprocurement of our business in Kentucky.
During 2020, we continued to build on our strengths and drive value in spite of the many COVID-related challenges we faced. In response to COVID, we successfully transitioned over 90% of our workforce to work from home over a period of just a couple of weeks back in early March. We accomplished this while providing uninterrupted service to our members and providers. In fact, we were featured in the World Economic Forum's Workforce Best Practices report for our COVID-19 response. We did all of this while maintaining high levels of member and provider satisfaction. Throughout the year, we distributed almost 7 million pieces of PPE to safety net providers, waived prior authorization and cost-sharing requirements, and committed over $13 million to fighting hunger.
Unrelated to the pandemic, we were also very involved in the Louisiana hurricane response, distributing 360,000 meals and 65,000 bottles of water while maintaining uninterrupted call center operations. In addition, we have continued to improve operational efficiencies. We have done this by combining best practices of the Centene and WellCare legacy organizations while continuing our drive for technology advancements and process improvement. For instance, we upgraded our clinical management system and committed $18 million to enhance telehealth for FQHCs and other providers. This commitment to supporting telehealth is a direct response to COVID-related challenges. Starting in late February, telehealth claim volume increased over 3,000% as the pandemic accelerated. Volume has come down somewhat over the past several months, but is still much higher than historical averages, and we expect telehealth volume to continue to exceed historical levels going forward.
In short, virtual care is yet another option in the wide array of care options our members are able to access. There also has been a dramatic increase in telehealth assessments as a percentage of all Health Insurance Marketplace assessments, as well as a 50%-60% increase in the number of assessments completed overall. We expect that this will benefit the Health Insurance Marketplace product risk scores going forward. After a successful 2020, we now turn our attention to 2021. We have several core objectives for the coming year. These include increasing provider engagement, expanding value-based contracting, improving clinical quality and member satisfaction, enhancing medical management, improving operational efficiency, and driving innovation at the market level. These objectives are interrelated and codependent, and achieving them will allow us to reduce medical and administrative costs, strengthen our relationships with our regulators, enhance revenue, and improve quality.
As a result, we expect 2021 to be a year of continued growth and development for the Markets division. Thank you. I will now hand things off to my colleagues to talk about other aspects of the business.
Hi, everyone. It's great to be here today. I'm Michael Polen, Senior Vice President of Medicare. I'm pleased to present to all of you for the first time since joining Centene as part of the WellCare acquisition. It certainly has been a unique year, but it hasn't slowed down our ability to reposition the Medicare business heading into 2021. I'm going to spend a few minutes today discussing our growth outlook, how we've used 2020 to position us well for 2021, and highlight a few of our longer term opportunities. Let's start with growth. You can see on the slide, this business has continued to develop, and we feel confident about our ability to grow into the future. With AEP coming to a close, we're pleased with our current performance, and we're optimistic about our positioning for the upcoming year.
As you heard from Jeff, we expect our 2021 growth rate to be above industry with a full year target in the mid-teens. As we think about longer term, we expect to be positioned to continue to grow above industry. With this year's acquisition of WellCare, you can see Centene's Medicare business now operates at national scale, offering products across the full Medicare continuum. As part of our multi-year strategy, we'll continue to expand into attractive new markets, go deeper in each of our existing markets through further product development, and increase our overall duals market share by leveraging our number one position in Medicaid. As we talk about national scale, it really does matter. 87% of Medicare Advantage growth since 2015 has gone to plans with 1 million members or more. Centene now has that scale, and we're starting to see some of the benefits.
Our distribution model has matured. We're gaining focus and real partnership from the large established FMOs and tele-digitals. This is allowing us to become more efficient with our sales strategy and drive larger enrollment share. Brand awareness is increasing, which plays an important role, not only in member selection and retention, but also in strengthening key provider and broker relationships. Our scale across multiple businesses provides us increased provider mind share and allows for us to partner with new providers in more meaningful, value-driven ways. Finally, scales allowed us to create more competitive unit cost positions and overall G&A leverage, which we can use to invest back into the business. Now, while it's been less than a year since the WellCare acquisition, we've been able to move quickly to integrate the two organizations and drive results.
We used the WellCare acquisition as an opportunity to bring additional Medicare expertise into the organization and reorganize the operating model to improve overall execution. With these changes, we were able to quickly achieve several objectives. You see a few of the highlights on the slide. We made significant strides on broadening our distribution network and increasing our overall enrollment bandwidth. We executed on increasing our footprint and going deeper in markets with comprehensive offerings. Finally, we jumped on the synergy opportunities within our cost structure and turned that into meaningful value to support our 2021 positioning. While we're executing very well heading into 2021, the most exciting thing about our business is we still have a long runway to drive both growth and profitability. First, related to Stars. We have material upside on our Stars program.
We're enhancing the playbook and making additional investments into the program, which will translate into real value over the next few years. Second, we still have attractive geographic and product expansion opportunities in front of us.
This will allow us to access more beneficiaries and drive more share in those markets that we operate in today. Finally, I want to highlight that we have a large base of highly qualified leads from our PDP, Medicaid, and marketplace businesses that will look to cross-sell into our higher value Medicare products. In closing, Centene's Medicare business looks very different than it did five years ago or even 12 months ago. We now operate a Medicare business at scale with an experienced management team and full enterprise commitment. We've quickly transformed the business into a national leader through strong, focused execution. We not only are optimistic about our positioning for 2021, but as I've shared, longer-term, we have some very actionable opportunities that will drive strong growth and profitability over the next several years. Thanks for your time.
Hi, I'm Drew Asher, Executive Vice President, Envolve Health. It's great to engage with you again, at least virtually. We thought it would be instructive to give you some insight into the breadth of Centene's pharmacy capabilities and how we've been leveraging them for the benefit of our businesses, and then review what we've been up to, but more importantly, where we are heading, including a recently announced acquisition. Centene has branded its pharmacy capabilities as Envolve Pharmacy Solutions, wholly owned by Centene. Under the Envolve Pharmacy Solutions umbrella, we have four businesses. First, a large PBM managing over $30 billion in pharmacy spend on behalf of our Centene businesses with clinical capabilities driving Centene forward quality and HBR initiatives. Second, a specialty pharmacy with over $3 billion in revenue, 13 dispensing pharmacies nationally, and over 150 limited distribution drugs.
Third, the market leading standalone PDP business with over 4 million Medicare PDP members, and finally, PBM capabilities on multiple platforms serving other payers and employers. The most important asset, though, is the pharmacy intellect and operating acumen of our 3,200 employees in Envolve Pharmacy Solutions. What have we been up to? Quite a bit in 2020. We have delivered on the critical pharmacy-related synergies supporting the WellCare transaction and have successfully merged Exactus, the WellCare specialty pharmacy, into AcariaHealth, the Centene specialty pharmacy, cross-leveraging limited distribution drugs, purchasing, and patient bases. We've been focusing on the best-of-breed for clinical initiatives into our health plans. Of course, where we're heading is more important. We expect to deliver incremental synergy in 2021 as planned for in the WellCare transaction.
Most of the work on this has been underway during 2020, and there are plenty of clinical initiative opportunities ahead. We're excited about continuing to deliver value to seniors through our low-cost PDP products. Despite some competition in the value space, we like our positioning, which has always been rooted in multi-year sustainability. We continue to work on rationalization of PBM platforms. We will consolidate over time both internal and external platforms. On the topic of where we are heading, we're actually putting some capital to work to drive growth in the pharmacy space. Earlier this week, we announced the acquisition of PANTHERx, a specialty pharmacy focused in the rare and orphan drug space. This specialty pharmacy serves some of the most complex members, similar to Centene.
We expect this to be a high-growth business, both top and bottom line, given the market and PANTHERx positioning as a leader. Most importantly, it adds a capability to Envolve Pharmacy Solutions that bolsters our expertise in serving medically complex patients and members. The vast majority of PANTHERx revenue is from third-party payers, which will continue as we work closely with pharma manufacturers of these often life-saving drugs. While we were certainly focused in 2020 on executing and integrating, we did not lose sight of opportunities and investments for 2021 and beyond. Thank you.
We are now ready to start our second question -and -answer session, where members of our operational leadership will take your questions. Our first question comes from Lance Wilkes of Bernstein. "Can you talk to strategy on leading with an owned PBM versus outsourced support from PBM partners and using your RxAdvance partnership? In particular, what capabilities are being used from each, and how are you positioned for carve out PBM opportunities?
Am I unmuted?
Yeah.
Hi, this is Drew Asher. Thanks, Lance, for the question. As I mentioned in my remarks, we're in the process of evaluating all of our internal and external platforms, we're doing this unlike two years ago. We're doing this looking through the lens of an enterprise at scale that has $30 billion of spend, plus and multiple assets across the pharmacy ecosystem. That process is ongoing, and we'll be spending time in 2021 on that.
Excellent. Thank you, Drew. This next question comes from Josh Raskin at Nephron Research. How are you thinking about the integration of behavioral health services as they grow in size and importance? Also, how does this influence your thinking about specific populations like the severely mentally ill? Now, this question, Michael wasn't going to participate in this operational Q&A. He's been talking a lot about behavioral health, so we're going to ask him to take this one.
Thank you. As I said, I was going to try and be quiet and silent, but it doesn't work out that way. Behavioral health is of growing importance to us. The board and I have had a lot of discussions about it. By example, Josh, we say that somebody's a newly diagnosed diabetic, after they see their endocrinologist, they should go see a psychologist and help them understand how to deal with it. We hear a lot of postpartum and OB sees a woman he thinks could use some psychological help before she leaves the hospital, get it done. The SMI population is growing, and there's a need. What's really interesting, and I think very important, is that there was a time when behavioral issues, there was a cloud over them. It's not something you want to admit to. That's not the case anymore.
People are willing to recognize they have the issue, and I think the fact that we're integrating it into the health plans, carve it in, not out, is going to be important. We're going to continue to build our capabilities in that sector and recognizing how important it is.
Michael, can I add to that, please, sir? Many of our states are asking us to serve not just traditional behavioral health, but also for the SMI population. We've been honored to actually serve the SMI population in southern Arizona since 2015. At the same time, there are certain states like Arkansas that is asking us in partnerships to serve the population. There's many of our contracts, like in Iowa and Kansas, that we have the opportunity to serve the population of SMI. There's even states like North Carolina that has an RFP right now that tailor plans, where they're looking to the local LMEs to partner with the existing plans such as we have in North Carolina. With this, there's a tremendous opportunity we've had and tremendous opportunity in the future to really provide value and outcome for this population.
If I could just add one other quick thing to that. We're working with several partners to implement telehealth capabilities across behavioral health. We actually see this as a huge opportunity to serve our members where they are. One actually really interesting data point, and this is very early data, but while we've seen virtual care visits normalize to a certain extent from the highs that they hit during pandemic, behavioral health adoption in the virtual care setting actually continues to grow. We are looking at this as a real opportunity to serve our members.
Great. Thanks, everyone. Our next question comes from Scott Fidel at Stephens. Can you provide some more details on the mid-teens enrollment growth in MA? Are there any products that are driving this growth or any geographic areas in particular driving the growth in Medicare Advantage?
Hi there. As part of our overall 2021 strategy, we were focused, as you heard, on really developing an enhanced comprehensive product portfolio with the idea to be able to have products available to all different types of demographics. What we've been pleased with is we're seeing very consistent growth across our different product offerings and across all of our geographies, which is continuing to give us optimism as we go into 2021 around our overall growth opportunities.
Great. Thank you, Mike. This is also a follow-up from Scott Fidel. Can you specify around the decline that you are expecting in PDP lives and how you see PDP margins trending year-over-year in 2021?
We're actually really pleased with the absolute level of PDP membership. We've always anticipated when the members had the first opportunity to reexamine post the Aetna to WellCare implementation, which was January 1st, 2020, that there'd be a little bit of attrition. Embedded in our guidance is 4+ million members. We believe that's where we'll come out through AEP. Really like our positioning with the low-cost products and supporting the administration also in terms of some of the pilots, including the insulin pilot.
Great. Thank you, Drew. Our next question comes from Gary Taylor of JP Morgan. Can you comment on the renewed deferral of care that is offsetting the sizable acceleration of COVID hospitalizations? The comment seemed to imply that October and November MLR might have been trending better than expectations. Given your first half, second half EPS cadence, it sounds like you may have concern that direct COVID-19 expenses could overtake the deferred care benefit.
Thanks, Gary. This is Jeff. Actually, what we have seen, I think the piece you're missing there is the revenue component. Remember, we last talked in October at our Q3 earnings call. We said, we think the full-year rate adjustment, the retroactive rate adjustments were going to be $0.5 billion . We said, "Well, no, it's $790 million." It's a lot larger. What we have seen, I would say, in October, November, is this total overall lower cost. Yes, you have higher COVID costs, you have lower non-inpatient, net total, if you just take the medical cost line, it's below the historical average, and that's what's allowed us to absorb this additional $290 million in the fourth quarter. We are assuming heading into 2021, a lower level of utilization.
I would say, not as much as the October-November phenomenon that we've experienced so far this year.
Great. Thank you, Jeff. This next question comes from Josh Raskin of Nephron Research. It has been a long time since Centene has bought back stock. Is the comment today about the evolution of the company and capital deployment or more about the current stock price?
Yeah. I think the first thing is that you have to do these stock buybacks under a 10b5, and so we don't actively have a 10b5 in place. I think what we're signaling is, we will be opportunistic, and going forward, as we look to deploy capital and try to drive that bottom line on the double-digit growth percentage that we're talking about today, that's an option and an opportunity. Again, you're going to have to compare deploying capital on that to all the other growth opportunities that you heard from Brent today and all the other avenues that we have to deploy capital into technology. We're going to be thoughtful about that, and I think it's an option for us on a going-forward basis that we haven't used historically.
Jeff, thank you for that color. The next question comes from Kevin Fischbeck of Bank of America. You talked about the $400 million Stars opportunity. How long will it take to get there? Given COVID disruption, is there any ability to improve before 2023?
Hi, there. As we know, Stars is a multi-year program, and it's got a performance lag built into it. That said, we are focused on continuing to enhance the playbook. We're making additional investments that are really geared towards the changes in the overall Star structure with the increased focus on customer surveys, and administrative measures. We'll continue to accelerate our performance. COVID absolutely has some impact as you think about being able to progress quality over the next year. As we think about what I said around enhancing the playbooks, and really thinking about additional investments, we do see the ability to accelerate our performance and to see good results in the coming two years.
Thank you, Mike. The next question comes from George Hill of Deutsche Bank. Can you talk a little bit about the PANTHERx Rx acquisition and why you felt it was important to have your own specialty fulfillment capacity as opposed to leaning on your pharmacy partners?
Hello again. Actually, we've been in the specialty pharmacy business since 2013 with the AcariaHealth acquisition. That's been a great business for Centene. We're now about $3 billion in revenue before the PANTHERx acquisition. This is a great business on its own merits. As the leader in government programs, including medically complex populations, beyond just the benefits of owning it for the business itself, we think we'll better understand the specialty pharma pipeline, clinical requirements, cost management aspects of these high-trending items. It is yet another member engagement opportunity for those PANTHERx patients that happen to be Centene members. We're really excited and can't wait to close the transition and welcome the PANTHERx team.
Thanks, Drew. The next question comes from Kevin Fischbeck of Bank of America. Is there any way to quantify the risk score headwind? Can that be completely overcome in 2022, either through coding or benefit design?
Yeah. I'm not going to specifically quantify the exact headwind. Obviously, I think you have more time in order to get the codes in, it depends on how many of our members actually get to the doctor between now and the end of the year, which obviously we're trying to facilitate. We've got an estimate in the forecast, I'm just not going to get into the details because we don't know the final number yet. Yeah. As far as the headwind heading in, there was a second piece to that question. It depends. It really depends on the pandemic, as Mike just mentioned. It really depends on how the pandemic progresses into next year, how long it goes. Obviously, I think it's the same thing on the quality story. I don't know, Mike, is there anything you'd like to add on that?
The only thing I would add is, as we think about our positioning for 2021 and setting the bids and the plans, is that we did expect a risk adjustment headwind due to COVID, and it's in line with our expectations as we're moving into 2021.
Great. Thanks both. The next question comes from Dave Windley of Jefferies. On telemedicine, did that growth come primarily through dedicated telemedicine companies or via video enablement of your existing network providers? How are you proceeding with reimbursement of telemedicine?
Thanks for the question. We can get you more details after the event, but in general, we're working with partners to enable telehealth across the board. As everybody knows, this is sort of a new world that we're in today, and we're seeing, as I said before, increased adoption of these capabilities, particularly in the behavioral health space. The reimbursement models that we're looking at are everything from standard reimbursement through to some pretty interesting experiments on the full risk side of the equation. But again, these are early days, and so we have a lot to see and learn as we go through it.
Thank you, Brian. The next question comes from Steven Valiquette of Barclays. You talked about Medicare now operating at national scale. Combining this with $100 million cost removed in Medicare cost structure, should we assume that Medicare margins will stay relatively steady going forward beyond 2021, or is there room for some expansion?
Yeah, I think you heard that Jeff touched on this earlier. Absolutely, as part of our long-term strategy, we will continue to focus on driving growth and profitability. As I mentioned, we have several opportunities in front of us that we can execute to drive both growth and profitability. We talked about Stars already. We talked about the opportunity to continue to grow the business through geographic and product expansion, and then continuing to be able to leverage the other businesses and to be able to drive scale, with the new national size that we have. We will definitely expect long-term to see growth and profitability continue to expand.
Great. Thank you, Mike. This next question comes from A.J. Rice of Credit Suisse. Services revenue are on track to generate $3.8 billion of revenue for 2020. The company indicated that specialty pharmacy represents $3 billion of revenue. How should we think about the growth of your other businesses that account for the remaining $800 million? What are the growth opportunities and expectations for these?
Yeah, real quick, I would say year-over-year, obviously, the guidance is absent the transaction that we've been talking about here with PANTHERx. What I would say is consistent year-over-year, the other piece of that is Centurion. Obviously, there's definitely growth opportunities there. We've won contracts in the past, but right now, in our guidance, we've assumed consistent service revenues on a year-over-year basis.
Thanks, Jeff. This next question comes from Gary Taylor at JP Morgan. Many have hypothesized that a Biden administration might seek to cut Medicare Advantage rates or risk scoring since the Obama-Biden administration did so. Do you believe the change of administration carries material risk for MA?
We look forward to working with the new administration, and what we've seen is support, on a bipartisan level. We've heard from Biden that he's supportive of the private healthcare sector. I think when you look at the value that MA's been able to show over the last several years as it relates to being able to control costs, to improve quality, and to see the overall popularity of the program continue to increase, we think that MA will still be a very strong industry, and we see good, strong growth, even under the new administration.
Great. Thank you, Mike. This will be our last question. This question comes from Eric Percher at Nephron Research. Drew, could you provide some perspective on the overlap of orphan disease focus at PANTHERx and the CNC populations?
PANTHERx's revenue stream, only about 5% of it today is from Centene or Centene affiliate members, and obviously, we expect that penetration to grow over time. It's a business that serves both third-party payers, third-party PBMs, works closely with manufacturers of these often life-saving drugs, and we'll get to further penetrate the Centene book, much like AcariaHealth has done over the past seven years and performed really well on behalf of Centene and its third-party payers.
Great. Thank you for that, Drew. Thanks to the team for the answers, and thanks to the analysts for submitting your questions. We will now move to a break. We will return to programming at 11:00 A.M. Eastern for our political panel led by Jonathan Dinesman.
[Break]
Welcome back. As we have done over the years, we have included a political panel of esteemed experts who can really, truly give you a true idea in terms of what we should expect as we go into 2021. Obviously, we are looking forward to working with President-elect Biden and his administration, as well as a new Congress, as we continue to make sure that we're providing high-quality care to all Americans, especially our most vulnerable citizens. With us today are Haley Barbour, who is Founding Partner of BGR Group, also former Governor of Mississippi, and the former Chairman of the Republican National Committee. We also have Cindy Mann, and Cindy is a Partner at Manatt Health, and she was also the former Director on the Center on Medicaid and CHIP Services. Last but not least, we have Andy Slavitt.
Andy is Senior Advisor for the Bipartisan Policy Center and former Acting Administrator of CMS. Before going to the panelists for their views in 2021, I wanted to spend a brief moment in terms of how we see things at Centene. As Brent Layton mentioned in his remarks, Centene has done incredibly well working with both parties. When we first looked at our strategy, it's based on one simple premise, and that is good policy is good politics, which allows us to work across the aisle with both parties. There was a time I stood before you all, and President Obama had just won election with a Democratic Congress, and there was a lot of uncertainty in terms of what would the Democrats and President Obama do in terms of the healthcare delivery system.
Obviously, they passed the ACA, and we've had incredible success with working with that administration and continue to do so today within the construct of that ACA. There was President Trump. President Trump also came in with a Republican Congress, and the questions and uncertainty really kind of focused on what would repeal and replace look like, would they be able to do so, and what would potentially a new healthcare delivery system end up as. Obviously, over the last four years, once again, Centene has been able to show, working with a Republican administration and then what became a split Congress, that we can work across the aisle. We've got President-elect Biden, and President-elect Biden is coming in off the premise of strengthening the ACA. That's what made him so different than his Democratic counterparts running for president at the time.
The one thing that's quite certain right now is even though we don't know the outcome of the Senate due to the Georgia Senate races, what we do know is that there's going to be a smaller majority for the Democrats in the Senate. However the things play out in the Senate, we're going to have a smaller or maybe a 50/50 split in the Senate. What that means is that those in the middle, the moderates on both the Democratic side and the Republican side, are going to have the greatest strength. We've already seen that with how they were really the ones who were able to get up and running another COVID package for discussion. We're very excited in terms of what the opportunities are out there.
We've seen on the Medicaid space that Republican and Democratic states, conservative, non-conservative, that in terms of the states such as Idaho, Nebraska, Utah, and Missouri have gone to Medicaid expansion. We'll clearly be watching to see what other states may be looking at more coverage on that front. We're clearly confident that we're expecting President-elect Biden to work at strengthening the ACA via regulatory means and potentially via legislative means. The one thing that is certain through this process is that in government care, both parties are focused on making sure that people have access to high quality, affordable coverage. It's going to be those companies that work well with government that are best positioned, and that's why we're so confident at Centene. With that, I would like to start off with going to Haley Barbour to give us his perspective in terms of the elections.
Jon, thank you. I should say to start with that Jon tells me I've got five minutes. With my accent, I can barely say hello in five minutes, I'm going to do the best I can. I was pleased to hear Jon's comment, good policies, good politics. I was political director of the White House for Ronald Reagan, that was one of his favorite expressions. Let's go back. My job to start off, let's look at 2020. Never been any year in our lifetimes like this, literally, it's across the board unbelievable. The first two months of the year, we had gigantic economic growth. We had the lowest unemployment in 50 years. We were seeing incomes go up, particularly among lower income people.
Then COVID came in March, within a few weeks, the whole thing turned around to where by late in the spring and early in the summer, we had depression-like, literally depression-like unemployment. Not only people losing jobs, businesses closing down. An unbelievable, unforgettable economic downturn, and at the same time, politics for the Presidential election was going on full speed, though not in normal ways. You'll remember that the news media and most of the pundits predicted that Trump would lose, and that this would be a blue wave, that the Democrats would really have a big election this year. The year went along, polling seemed to reinforce that. Democrats outspent the Republicans, in numerous ways and in numerous states. Almost every Republican Democratic senator incumbent got outspent, where normally incumbents outspend their challengers regardless of party.
At the end of the election, when all was said and done, Trump did lose. I say that because I am one of those who believes that in 2016, it was less a matter of Trump became president because he won, than it was a matter of he became president because she lost. We saw that replicated this time. Biden won, but more as a matter of Trump lost than Biden ran the superior campaign and won. Interestingly about that, Biden got 306 electoral votes in defeating Trump, which is literally exactly the same number of electoral votes that Trump got in defeating Hillary Clinton. It was the largest turnout in American history. Donald Trump got almost 75 million votes. He got the most votes of anybody in the history of American presidential politics, except one guy, Joe Biden.
Joe Biden won the election by several million popular votes. The electoral vote was relatively close. As I say, it takes 270, he got 306. The Democrats were anticipating, as Jon said, to take over the Senate. In fact, that did not happen, or has not happened yet. In the Senate races that have concluded, the Republicans have 50, and the Democrats have won 48, which means that the two Georgia seats are determinative. If the Democrats win both Georgia seats, make a 50/50 tie, then Vice President Harris will break the ties. If either or both of the Republicans win, then the Republicans will have a majority.
This is very important because many on the Democratic left, and some including the president, talked about major changes in procedures, like doing away with the filibuster, statehood for D.C. and Puerto Rico, the new Green Deal, and you can go down the list of different things that they say that they would do if they have the majority. We'll see. This is a very consequential pair of elections down there the first Tuesday in January. In the House, again, all the predictions were that the Democrats were going to carry the House by a bigger margin. They had a margin of about 40 seats. Instead, looks like they're going to end up with a majority of around 10 seats.
Right now, there are two elections that have been contested and are not decided for that reason, and it means that the Democrats have 222 and the Republicans have 211. Very close, and that was one of the reasons that Jon made the point for us, moderates are going to have a whole lot more power if party voting is not just put hard into place. With so many moderate Democrats, almost all of their pickups, where they did have them, were moderates. The Republicans didn't lose any seats in the House. We're going to have a close time here. Let me just mention, Republicans picked up one governor, won eight out of 11 governors races for a net gain of one. Republicans now have 27, Democrats 23. The Democrats did not win one house in the state legislature.
Some of you may remember that President Obama, about three years ago, pronounced his former attorney general was going to be running a program to take Democrat victories in the state legislatures, because this year is the census, and that means reapportionment of the U.S. Congress, typically done by the state legislatures, would happen in the wake of this election. As it turned out, there was another big green wave that went kaput. The Republicans did not lose one house in one legislature in the United States. That's how we come back into here. I want to just make a couple of closing points. Historically, in the United States, when we are at parity between the two parties as we are now, usually we're at parity and everybody's bunched up in the middle. That was the case in 1960, the case in 2000.
It has not been the case for the last few years, the Trump administration, the Obama administration, maybe the last part of the George W. Bush administration. We have been at parity, but there's been no middle. The question is this new arrangement where you've got the Democratic Party's gone through a lurch to the left and then did not have a very good election, and in fact, the guys that did the best for them, guys and gals, were their moderates, their centrists. Are we going to see that movement to the left continue, or are we going to see a move back toward the middle? Certainly, President Biden gives the impression, and I have no reason to think it's not totally accurate, that he would like to govern more from the middle than the left. We will see. I will say this about Centene as I close.
I was governor of Mississippi in a very hard recession, 2007, 2008, 2009, you all will remember well. One of the things that governors and people that have to deal with healthcare and big healthcare issues and spending. They're looking for people that want to treat them fairly, and we learned that Centene was a great partner. They helped us save money. They kept their word. They were innovative. We first allowed them to come in with another company, and we let them have 15% of our Medicaid population under managed care. Before I went out, four years later, that was up to 85% under managed care. It is because of the results and because of the effort primarily that Centene made to make this go forward.
Hopefully, that is the kind of outcome that a Biden administration will have because they will have to rely a lot on states because of the state programs, and I'm sure that they would like to see everybody go to expanded Medicaid and go forward from there, working together. Interesting time, to say the least.
Well, thank you so much, Governor. Next we will go to Cindy Mann.
How's that? Sorry. Sound okay? Yeah. Okay. Thank you for having me. Great to be with you all virtually, and always informative to hear Haley Barbour and his take on the world. I appreciate that. I'm going to focus a bit on Medicaid, obviously an important area for Centene. I'm going to look at three different areas. Just to give you a little, what's going on in this budget and enrollment, what's happening or could be happening on coverage expansion, and then specifically on managed care developments.
For each of those areas, because Medicaid is, of course, as you all know, a unique federal state program, I'm going to talk a little bit about it from the state vantage point, and then hit on what might be the likely issues or issues to watch for in terms of a Biden administration and a new Congress. Let me start with the budget and enrollment issues. Obviously at the state level, everything has been COVID. That's been true generally for states, and that's true specifically around their Medicaid programs. That's affected states in a number of key ways, as I'm sure you can all imagine. Let's just talk about budgets first. Coming off of several years of budget surpluses at the state level, states are seeing big changes on the budget side and big changes also on the enrollment side.
Let's take budgets between March and August of 2020. State tax collections were 6.4% less than the same months in 2019 on average. That may not sound like a deep dive, but for states that have balanced budget requirements that's creating really significant dislocations in their budgets. I will say, when you look across the states and you look at the state projections going forward for 2021, it's pretty uneven and also very difficult for states to project. I think a lot about the state budget story is deep budget problems, but the duration and the depth is going to be both vary by state and difficult to project. Let's look at enrollment, because Medicaid, as you know, is such a big part of state budgets.
The size of the Medicaid program, therefore, has a lot to do with how well states can meet their obligations in a constrained budget environment. We typically see rising Medicaid enrollment when we have a downturn in the economy. As Haley talked about, we certainly have a downturn in the economy, unexpected as a result of the pandemic. It was a little bit slow to kick in, and a little bit uneven, and right now we still don't have national enrollment data on Medicaid. We've been looking at the state data, and if you look at the states that report through November, overall enrollment for Medicaid has increased by about 12%, but big ranges. That's the median state. Some states 20% or close to 20%, some states it's 6.5%. That's the range.
If you look at the non-elderly, non-disabled adults, which is really the key group that would be impacted by the downturn in terms of job losses and loss of health insurance coverage, both expansion adults and the non-expansion adults that states are otherwise covering, much steeper enrollment growth that we're seeing. In the median state for expansion adults, about 22% growth and for non-expansion, non-disabled adults, so that's your parents, your pregnant women, the median state is seeing about a 32% growth in enrollment. Really steep enrollment at the same time state budgets are being squeezed. Therein lies a key problem and a key factor facing the landscape in the Medicaid program going forward. One of the key questions for states that bring us back to the federal level. Will there be additional congressional action on state and local relief?
We still don't know whether the lame duck Congress is going to come to some agreement on COVID stimulus package. What seems pretty clear is even if a package emerges in the next day or two, that state and local relief is likely not going to be in that package, and so that remains a big question for January. I think everybody expects, even if there is a package now, there'll be potentially another package, or certainly the Biden folks will want to push hard for another package in January, and state and local fiscal relief will be really important and really important to the outlook for Medicaid. Of course, big questions around what will happen to enrollment and revenues over the long term. Going beyond the basic budget picture, as noted, expansion moved ahead over the last couple of years, Medicaid expansion.
Let's see where we are right now. Just to give you a point of reference, in 2014, which is when the ACA coverage provisions kicked in, became effective, we had about half the states, a little less than half the states that were taking up the Medicaid expansion at that point. We now have 38 states have expanded, plus the District of Columbia, and that comes on the heels of successful ballot initiatives in probably states that wouldn't necessarily be top of mind as to where you'd expect a Medicaid expansion. It's very popular whenever it hits the vote and the ballot box. Ballot initiatives were successful in Nebraska, Idaho, and Oklahoma. Oklahoma being the state that the expansion doesn't kick in until 2021, but the other states have already actually started enrolling people.
Is it reasonable, given what I just said about budgets, to think about states moving forward in the year ahead? Well, on one hand, they have to come up with 10% of the share of expansion. On the other hand, hospitals have largely been open to financing that portion of the state expansion through higher provider payment rates and provider taxes, I'm sorry. The expectation is it doesn't necessarily have to come out of the state general funds, and expansion brings an influx of federal dollars, an immediate influx of federal dollars. It's a mixed bag in terms of the budget situation and an area where we think there's likely to be some continued consideration of expansion. The Biden administration is going to be very focused on closing that coverage gap. The candidate Biden had proposed a public option.
It to be established at the federal level. That was partly a marketplace proposal, but it was partly a close the coverage gap proposal. His proposal was that in the states that hadn't expanded, if there's a public option on the marketplace, that the people in that coverage gap could enroll. I think it's pretty unlikely we're going to get a public option passed through Congress, regardless of what happens in the Georgia election. I think that means that the Biden administration will focus a lot on coverage expansion, but will do so through its administrative tools. They are substantial. They're not infinite, but they are substantial. The big question will be, what is the Biden administration willing to do through waivers? He's going to do clearly very different approaches on waivers, Medicaid waivers, than the Trump administration.
The Biden administration has a number of ways to use a combination of carrots and sticks, mostly around dollars, to be able to interest states into moving along on expansion and to close the coverage gap. I think we'll see a lot of changes in waiver policy, and much of it aimed at how do we make it even more attractive for the remaining states to come and expand. Finally, let me touch upon where we're going on managed care in the Medicaid program at the state and federal level. Increasing heavy and ever-growing reliance on managed care. You see it all over the country, even though we have a high penetration. About 38 states rely on comprehensive managed care. We continue to see states join that group, as well as states that already rely heavily on managed care doing some expansions within their managed care framework.
For example, we see California, a heavily managed care state, they are creating state-only managed care opportunities, state-funded for the undocumented, but also they're moving in in their regular Medi-Cal program, long-term services and supports into managed care. Oklahoma, in the face of doing the expansion in 2021, the governor there has proposed to implement managed care. It's one of the smaller number of states that haven't done any managed care. They've issued the RFP, and that's moving forward in Oklahoma. We also have seen a number of re-procurements, and including some big states, Michigan, California, states that haven't done re-procurements in a while. What are the states looking for when they're expanding managed care, when they're doing re-procurements? I think areas very much aligned with Centene's strengths and priorities.
They're looking for better integration, behavioral health with physical health, and also bringing in long-term services and supports to integrate with both behavioral and physical health. They're increasingly looking at social drivers of health, housing, food insecurity, violence, interpersonal violence, issues that can really bring up healthcare costs and interfere with positive health outcomes. There was a growing focus on managed care in 2019. We did a review of all of the managed care contracts and what they required of managed care plans on social determinants. It is not a fad anymore. It is definitely part of the Medicaid delivery system landscape. We've seen, if anything, more focus during COVID-19, because of obviously the dislocations and the hardships that so many families have faced.
We're also seeing states focus on particularly vulnerable populations, justice-involved people being released from jail, for example, foster care kids, and high-cost, high-needs individuals with also a vantage point on social drivers of health. We've also seen a pretty quiet, I say quiet because there's so much going on in this world it's sort of not been front and center, growth of drug overdoses. CDC just released a report that showed a 12-month increase in drug overdose in the year ending May 2020, with the largest increase starting in March through May coinciding with the pandemic. What might the Biden administration do? I think they're going to support more investments into managed care.
They're going to support more investments into social determinants, which will give states some more dollars to actually spend on this and not just make requirements for plans, but really expect plans to get involved and deliver on the interventions themselves. A lot of states have been pent-up demand for these justice-involved waivers to help them get into jails before release. I think the Biden administration will approve those. There's a lot of states interested in doing more on pregnant women and reducing the health disparities there, and I think also likely we'll see new initiative on dual eligibles. Bottom line for me to wrap up, from the state's perspective, Medicaid has really been moving steadily forward in terms of reliance on managed care, while also state governments have been expecting more of their managed care partners.
COVID has interrupted a lot of the regular business, but it's also accelerated trends in key areas around social drivers of health, around the focus on high-needs, high-cost populations, and a continued growth in the scope of managed care in states. We have re-procurements coming up in several large states. We'll see enrollment continue to grow for some time, though difficult to predict. At the federal level, we're looking for the Biden administration to reverse course on the kind of waivers that the Trump administration has approved, to do what they think they can do to boost expansion when there's an opportunity to do so, and to focus on some of these priorities, social determinants, behavioral health, specialty populations, and health equity.
Thank you so much, Cindy. Really appreciate it. Next, we will go to Andy. I know we do have quite a few questions in the queue. Andy, hopefully closing it out, if you could stay as close to five minutes, because we definitely want to make sure that the questions from the folks get out because they're really looking forward to hearing from you all. Next, it's you, Andy.
Thank you. Thanks, Jon. I'll try to be quicker. I want to thank Michael. I just have to do it to start with this. It was a few years back when I was in the Obama administration. One day I picked up the phone and called up Michael. This is a time when the ACA was just moving from not profitable to profitable. Michael picked up the phone. I said, "Michael, we have a market that is desperately in need of someone to provide service to the beneficiaries." Michael said, "You can count on Centene. If people need help, we're there. We'll work on the details." There are two points to that story. One is that I think, I think Haley said this, the best partner wins. People who understand government, people who are going to be supportive of government. Not everybody does that.
The second thing is it turned out to be an immensely smart decision for Centene, because it was just as the market was turning, it won a lot of market share, and I think it showed me that the character that shows through in companies that know how to partner with the government and understand that the government has challenges, and the government cannot solve these challenges without good partners, will succeed. I'll go quickly just to give you maybe a little bit of insight at the federal level and what's going on inside the Biden camp. Biden has stated four priorities for this term: recovering from COVID, the economy, racial justice, and climate. What didn't you hear there? You didn't hear healthcare. For the first time in three presidencies we have somebody who is not making major healthcare transformation a part of his goals.
I don't care if he had 58 votes in the Senate. Healthcare can suck the oxygen out of the first two years of any administration, and Joe Biden's decided that's not where he's going to spend his chips in Congress. He ran on that. This is not different than Joe Biden ran on being a unifier. He did not run on creating difficult lightning rod issues, which it's been for the last few presidents. Even if the Democrats were to win in Georgia 50/50 is a very tough way to govern in the Senate anyway, because every senator becomes the most powerful person in the country in their own minds. It's very hard to get things substantial done. Not that there won't be potential for incremental things that are tagged on to other bills. Cindy's exactly right.
You'll see most of the work that comes out of Washington will come from the agencies. You look at those four priorities, and among those four priorities, you hear some things that aren't exactly healthcare, but touch on healthcare. Probably the thing that's to focus on most is COVID right now. I think it's just like in 2008 when the presidency was hinged at the beginning on turning around the financial recovery, which tanked at the end of the Bush years. The entire Biden presidency will live or die by how well and how quickly he can get the COVID response turned around. We are, in January, probably going to be at a point where 5,000 - 6,000 or more people per day are dying in a single day.
Most of the models, and I don't know whether to believe them or not because I'm not a professional at this, but most of the models say that we are about only halfway to the number of deaths that we'll suffer in this country, even under a scenario where the vaccine rolls out next year. I think you'll see him do a bunch of things differently from the current president, including working the bully pulpit pretty heavily, trying to get support for people out of Congress, working on getting people back to school through testing very aggressively, making people feel safe, and a bunch of the operational levers that Trump just decided not to pull very aggressively. It's going to be a challenge, and he won't get there unless he can get people to pull together, and I don't know how he does that.
He's putting a lot of great people on this because I think he knows how important it is. One of the other things that I mentioned was racial justice. Why is that important? It's important because not only do I think social determinants of health are important, but I think very explicitly, every policy will be looked at from a standpoint of how does it affect people of color, people in rural America, people who are of low incomes, seniors, less fortunate people, but very explicitly race. I think that's always been kind of in the background as we've talked about social determinants of health, but it's not been as explicit as I think it will be. I think you will have senior people in the White House and in the agencies who are focused on this.
One of the things that I tell people who come into office is the White House has their priorities. Whatever is in the White House priority, that's yours in the agency. Generally speaking, that's yours. By yours, it's the health secretary, it's the head of CMS, it's the head of CMMI, it's the head of OMB, it's the head of the Domestic Policy Council. Those people will get to determine most of the things that impact your world. Now, there's a few things we know, which is that they believe that the people who are the target Centene customer and member have been getting a raw deal. I think that is a net good thing. What we know is that they need partners like Centene to be able to be successful.
We know that Centene has people like Kevin Counihan, who knows how this works inside the government, inside and out, and knows how to partner with government. What does all this spell if I sum up? It spells stability. We're not going to have the kind of crazy big changes. It spells growth, because we're going to have growth from all of these programs, Medicare, Medicaid, and the ACA. It spells an opportunity to partner. I think that's an opportunity for the next few years that if we can make progress, I think would be welcomed by the country.
Thank you so much, Andy. We will go to our first question, and it's to Andy, and that's what do you see a President Biden doing in those first 100 days to potentially strengthen the ACA?
Xavier Becerra, who is the new Health Secretary, someone who I got to know pretty well when I was in Washington, D.C., is deeply familiar with the ACA. He was part of passing it. He is also someone who is familiar with the ins and outs of how people qualify for coverage, how some of the regulations work along the lines of special enrollment periods and all of these kinds of details. I suspect that the easy thing will be that they will look at the things that the Trump administration did to hinder growth or to make the market more confusing and get rid of those.
There will also be people involved in the government, including Kevin's former deputy, who is going to have a big role in whatever happens to the ACA, whether she runs CCIIO or whether she runs DPC, whether she's a PAD, and who's very close to Kevin, her name is Christen Linke Young. She's going to be one of the key decision-makers over the next few years. As Kevin could tell all of you, she knows every word of that inside and out. I think you're going to see hundreds of little things that are maybe too even small for people to even know about, that are all going to advantage people who haven't been aware of, haven't seen the subsidies, haven't had the opportunities, and I think you're going to see them be fairly creative in that regard.
I think they want to make the ACA a mainstay of how people grow their coverage.
Next, we've got Jen with a question.
Hi, everyone. Thanks for joining us. We do have some questions from the audience. The first one comes from Matt Borsch at BMO Capital. How do you think the Biden administration will differ in terms of regulatory approach to Medicare, specifically Medicare Advantage?
Cindy, you want to start or you want me to start?
Go for it, Andy.
I think we're about to see hey, Matt, it has been a while since we've talked. I think there's some rules coming out, there's some things coming out from the Trump administration before they leave that are pretty major models that are fairly aggressive in Medicare. The first test of the Biden administration will be to see what they finalize and what they don't. I don't think that could be known yet, because I don't think we know who's sitting in the CMS chair. We don't know who's going to be sitting in the CMMI chair and the head of Medicare chair. We know some of the people who are around for those roles. I expect more continuity than not. We're used to seeing a lot of very public differences around things like repeal and replace of the ACA.
When you get underneath that, there's pretty broad agreement on many of these things. Medicare Advantage is here to stay. There's no question about that. There is some question about whether Medicare Part D and Part B get some reforms on the pricing side, and I think that will happen eventually. Whether it happens now or not, hard to know. Given Chuck Schumer's support and many others in Congress, I don't think there's a scenario under which Medicare Advantage gets beat up too badly. Then I'll go finally to Cindy Mann's point. People are realizing that health is more than just about healthcare benefits. People are trying to find ways to be creative and allow the program to meet other needs that people have. I think that's good for society, and it's that good for Centene.
I think that's all right. One thing I would just quickly add is there are going to be some big questions in Medicare about what they do around telehealth. The Medicaid underlying statute allows the blossoming of telehealth that just happened. It didn't rely on COVID-specific new flexibilities, but that's what pushed states to move forward. Medicare, some of the changes are going to require potential statutory changes, regulatory changes. It's a deeper infrastructure change to keep telehealth strong post-pandemic. That'll be a big question.
Next question, Jen.
Great. Yeah. Great. With that, we'll go on to our next question. It comes from Josh Raskin at Nephron Research. We touched on some of this, but maybe specifically through the CMS lens. What do you think Biden is looking for in the next head of CMS, and what would you expect to be the major areas of focus?
Well, thanks, Josh. Obviously, good looks has always been a prerequisite for that job, and that won't change. I will tell you that they're not making that role as early a priority as they obviously did CDC and as that they will with FDA, because they don't view it as critical to the things they have to do today. Obviously, the things that they have to do, payment policy, I think they'll be on top of. Nursing home regulations, they'll be on top of. The thing about the Democratic side is, and I don't know whether Haley would agree with this or not, but there are just more people. You can't walk 5 ft in that run into someone who could be CMS administrator in Washington from the Democratic side. There's just so many health policy people there.
There are a few of the finalist candidates, all of whom I think would be terrific. I don't think that the choice will be somebody who brings a major agenda. I suspect it'll be someone who brings a real love for those programs and the ability to administer those programs, and someone who's smart, knows how to run the agency, and hopefully has some experience with the agency. The other thing I would add with that is, with the Trump administration, the one thing that governors talked about was the great access they had to not only the White House, but more importantly, to the agencies. I fully expect, with states looking at that waiver process, they're going to be looking for somebody that does have those strong relationships with the states, because that's going to be critical in terms of the coverage opportunities.
Yeah, I think that's right. It's always been this balance of, do you have that expertise in the Administrator? Do you rely on the Medicaid agency to bring that? Traditionally, CMS Administrator has been very Medicare focused. That was not necessarily the case in the Trump administration, where the Administrator was very Medicaid focused. I think Andy's right. They're looking for somebody who can run it well, cares a lot about the programs. I think that the two things that'll also be interesting right off the bat is, can they be effective in helping on the COVID response? Everything, at least for the short term, is going to be COVID. Then secondly, going back to one of Andy's points too, in mind, which is they are really focused on the racial equity issues.
I think thinking about whether it's a person of color who runs it or somebody who's going to be very sensitive to and attentive to the issues of disparities will be high on their list.
One small thing that Cindy made me think of. Policy for people with disabilities. I think you pick some groups that have been long ignored. While this won't be a shift to the left, I think Governor Barbour's got that exactly right. There will be groups of people that have been long ignored because they're Democratic constituencies, people with disabilities, transgender community, people of color, what have you. You can imagine there. I think those will be very high priorities. I think you'll see. If Centene has innovative and creative solutions for, say, providing long-term care, disability community, et cetera, I think there's going to be interesting interest in that.
Great. In the interest of time, I think this may be our last one. We want to be mindful of everyone's schedules, but this final question from the audience comes from A.J. Rice of Credit Suisse. It's a broader question. Do the panelists think that at any point attention turns back in Congress toward reducing or containing the federal deficit? If they do focus on the deficit, what kind of impact would this have on healthcare policy?
Well, let me say this. The Medicare Trust Funds, which is different from the deficit, but I think it's the same general way you're going, AJ, is that you have, right now, the Medicare Trust Funds due to become insolvent in 2024. I would say that's part of the work of the Trump administration, was, I think, quite honestly, neglect in that regard, and in large part because I think they would've liked to see the ability to reform it in the second term by doing something more significant. That's going to be an issue. If you have the Medicare Trust Funds expiring in your term, you're going to have to do something. Whether they can do something without Congress or whether they need Congress will be interesting.
Look, I think the broader question around the deficit is going to be a very interesting debate because you have a lot of people whose message out of the pandemic is going to be, "Wow, we got a lot to fix." Whether it's schools, whether it's state government, city government, investment in public health, a list a mile long. Then you've got other people who will say, "Gosh, we spent a whole bunch of money during this pandemic. How are we going to catch up or make it up?" Now we've got historically low interest rates, but this isn't an economic question, it's a political question. It's a belief in what do you think the role of government is type of question. As I think Governor Haley Barbour said, exactly right. We got a split, and we got a split with very little ability to compromise in the Congress.
I think this is going to be one of the potentially interesting debates should we come out of this. How quickly will we be moving on and how quickly will we try to address some of the wrongs? I think that's going to be a big fight between both parties on a policy basis.
If I could just make this one point. I believe that we are not going to see politicians really ready to step up to the plate and try to make meaningful reductions. When I say reductions, I mean real reductions in our federal debt until the world quits buying our debt. Right now, the average American thinks this isn't a problem. We can sell all the bonds that you can imagine, people all over the world will one day, I don't know what day, what year, what decade. One day the world's going to wake up and say, "We're not going to take America's debt anymore. We're not going to buy their bonds because they're too deep in debt, they're not doing anything about it." I don't know when that'll happen, whether Republicans or Democrats, both of them got plenty of blame on their hands.
Governor Barbour, when you look at the states, and heck, you were in the middle of the recession when you looked to go into managed care. You all have to balance those budgets at the state level. What would you expect from governors as we're dealing with the recession, kind of like how you dealt with it?
Well, of course, the different federal programs take pressure off of what it takes to balance your state budget because you're getting money from the federal government, to take the place of state funds. If the federal government had to balance its budget, it would be a very different country. There are a lot of people that think that might be for the better.
All right. Well, thank you all very much. Really appreciate the informative discussion. Next, we'd like to go to closing, our Chairman and CEO, Michael Neidorff.
Used to wearing this, I forget to take it off sometimes. Before we adjourn, I would like to take a moment to summarize what you've heard today. I also want to thank the team that put this together. I want to thank the production people that dealt with the multiple locations. It was just phenomenal. It was a real team effort to make this happen. We heard before, this is what? The second or third virtual meeting we've been doing. We virtually are getting used to it, but we'd only get too used to it. We can't wait to get back face-to-face. In summarizing what you've heard today, simply put, the underlying business of Centene, excuse me, remains strong, and you can be assured that we will stay true to our principles.
2020 has been a remarkable year, during which we have remained focused on several key priorities, and some of these things you've heard before. First, the safety and wellness of our employees. Second, ensuring uninterrupted access to care for the very vulnerable population that we serve. Excuse me, swallowed wrong . Third, protecting our providers by removing administrative burdens related to COVID-19 treatment and testing. Fourth, support our state partners through challenging times and strengthening our already well-established partnerships. Lastly, and very importantly, ensuring our results meet shareholders' expectations. Most importantly, that you are in a position to be proud to be a shareholder of this responsible company. The meeting today was intended to provide additional exposure to our senior and most senior staff. Unfortunately, not everyone can join us today because of social distancing and how many people in the rooms, other restrictions.
I look forward to having our full team participate in the future. I want you to know that they are as vital as important. We have people such as Jesse Hunter, our Chief Strategy Officer, Brandy Burkhalter, Chief Operating Officer, Marcela Hawn, our Chief Communications Officer, Chris Koster, General Counsel, Ken Yamaguchi, Chief Medical Officer, Shannon Bagley, my Vice President Chief of Staff, Matt Snyder, Chief Compliance Officer, among others. All are important members of our team, and I look forward to all of us being together next time for future investor days. I intend to showcase them so you really get to know them. I hope our conversation today gave you a sense of our day-to-day activities, our opportunities for growth, and the breadth and depth of our technology capabilities.
I don't think I am overstating it when I say we have the strongest, most capable technology group that you will find on any team. We are united in our desire to delight our members and providers, and moving forward, you can expect to hear more about how we are improving quality and simplifying the healthcare delivery process for all our stakeholders. Turning briefly to the Health Insurance Marketplace for what I expect will be the last time. I know there is likely some disappointment in the results, but I would like to emphasize what you've heard before. First, we are not participating in a price-related race to the bottom, and will continue to take a long-term sustainable approach to pricing as we always have. Second, we will not provide a limited network that encourages out-of-network utilization and can lead to surprise billing and other problems.
Thirdly, we will not compromise our quality of service for our members, providers, and state partners. We will continue to stay true to our principles and maintain our overall strategy, which has been successful, and will continue to be successful. In closing, I want to share something I've been thinking about recently. I've been thinking about what makes a truly great and well-respected symphony orchestra. In that caliber of organization, every musician has the capabilities to be a soloist. They come together to produce a quality product of beautiful music. At Centene, we are a symphony, comprised of remarkable people with the talent to be soloists, but who are united by a mission and work in concert to meet the needs of all our publics. With that, I'm going to close by wishing you all a most blessed holiday season, and that you be safe and healthy throughout.
We look forward to seeing you in the new year. Thank you.