Okay, we're going to get started with day three of the Stephens annual investment conference. I'm Scott Fidel. I'm the Healthcare Services Analyst, saving some of the best for last here on day three. We've got HCA with us today. HCA, as all of you know, is the largest operator of acute care hospitals in the United States, as well as having a pretty vast arsenal of outpatient, ambulatory, and other services as well. Here from the company today, to my right, we've got Mike Marks. Mike is the Executive Vice President and Chief Financial Officer, and Frank Morgan, who's Vice President of Investor Relations. So, first of all, gentlemen, thanks for coming again to the conference. It's great to see you.
Mike, I think what we'd want to do just to start out, and we've been trying to do this just with, unsurprisingly, just given the timing, with all the companies here this week, is just, sort of talk through the elections, and some of the implications, for HCA and your views on the, you know, some of the key areas to focus on. Clearly, we've been getting some updates on some of the staffing decisions, which, unsurprisingly, I guess, as well, are a bit unconventional, but certainly, it's going to, I'm sure these folks, if approved, will be leaving their mark on the healthcare system.
So, Mike, I think maybe just to sort of start out with, obviously now, you know, we've had some of the initial reactions, you know, in some of the stocks, and investors are still absorbing the information here. You know, we've spent, maybe to start out sort of the opposite direction, because there's been a lot of focus, obviously, so far on the exchanges, and then on the Medicaid supplemental payments, and certainly do want to give you guys an opportunity to talk about that, but also just curious from more of the second derivative effects as well. It's certainly likely that we'll end up seeing, you know, more impacts beyond that. So, why don't we start out with that?
You know, clearly, you know, any incremental comments you want to make on the exchanges and on the state supplemental payments, definitely happy to hear that from you, but also, as you've all been sort of working through your thoughts around the elections, any other incremental, you know, I guess, impacts or potential implications that you're considering as well.
Sure. Well, good morning, everybody. You know, so what we know now is, you know, the Republicans are going to sweep, right? They're going to have all three branches of government. I think, you know, it's important to note that the majorities in the House and the Senate are going to be tight, you know, 53 seats in the senate and maybe even tighter in the House, where, obviously, a few races left to be called. So, you know, I think that's part of the understanding of what can get done is just, you know, the very slim majorities in the House and the Senate, and then, you know, how does the legislation move in, you know, through this.
I think, from our perspective, the, you know, President-elect Trump and the administration, they were pretty silent as to healthcare policy as we went through the election process, starting to learn a little bit more as they make their selections and nominees for key health agencies. But, you know, I think, other than healthcare exchanges, which we'll talk about here in a second, obviously, and, you know, we can talk about supplemental payment programs as well, you know, what we always pay attention to is government reimbursement, right? If you think about kind of 50% of our volume is Medicare and 17% or so is Medicaid. So we're keeping a very close watch on things related to governmental reimbursement, in potential changes. Not aware of anything moving in that regard that's material, but, you know, just like you guys, the, there's a lot of unknowns still, right?
We got to get the nominees through congress, and then they've got to start articulating, you know, what their goals and objectives are as it relates to health policy. So, you know, other than exchanges and the like, supplemental payments, really, that's the third leg that we'll be watching carefully, Scott. And I'm happy to talk about exchanges if you want to do that now or whenever.
Yeah, yeah, I think we should, just since we're in that topic, and, you know, maybe we don't have to just talk about 26 and beyond as well. You know, maybe sort of layer in 2025, and you've talked about maybe just to sort of set the baseline there, expectations or a projection for, potentially around 8%-10% growth in your markets, in terms of the exchange population. You know, we've had from the payers a bit of a range, you know, that we've seen come out, from some of the companies that focus on that market at the higher end. Oscar has talked to up to around mid-teens type of growth.
Centene came out with a bit more of a conservative view, you know, walking through sort of a mid-single-digit growth outlook and brought up a few different considerations around their expectation. Clearly, you've been in markets, your leverage to markets that have had outsized exchange growth, a number of key states that haven't had ACA Medicaid expansion and have really leaned into that. So maybe can you talk to sort of that projection, the 8%-10%, how you arrived at that? And, you know, I know there's not much data out so far for the open enrollment period, but to the extent that you may have some types of indicators that you're tracking, you know, based on whatever you're seeing, how you feel about that expectation?
Yeah, obviously just, you know, as you would expect, and we refine our projections based on our markets, and so, you know, for us, you know, 50% of our hospitals are in Texas and Florida, so that heavily weighs on our thought process around understanding what could happen with healthcare exchange enrollment in 2025, and then you think about other, I would call them even kind of, you know, red states, you know, pretty Republican-dominated states that also did not expand Medicaid, you know, Georgia, South Carolina, and the like, so in these states, you know, we are studying, not only our current enrollment levels, in healthcare exchanges, but all the public data, and we don't have access to a lot of data that you guys don't, right?
But if you just kind of tailor the projections data for our specific states, the 8%-10% was our best estimate or range. I mean, you can get higher than that, but that feels right. So, you know, if you think about Texas and Florida as an example, it's about 5 million of the 21 million enrollees now in the healthcare exchanges. So, you know, those two states are already pretty heavily supporting the healthcare exchanges. And so I think 8%-10% is our best guess right now of what enrollment growth will be for healthcare exchanges in, you know, in 2025. And just to put that in context or perspective, you know, this year, we're up over 30% in enrollment in our state.
So, you know, when you kind of drill down to our specific markets, that, that 8%-10% feels right to us based on all the data that we can pull.
Okay. And then, so I guess when we're thinking about that sort of exit rate for mix from the exchanges, you know, you're generally in sort of that mid to high single digit, maybe closer to the high single digit sort of run rate in 2024, right? On sort of the revenue basis, revenues being a bit higher than volumes, just given that the exchanges are a solid payer, maybe not at par with commercial group, but probably the second best payer after that, right? So I guess that would sort of imply basically around a high single digit type of exposure. You know, as your, I mean, obviously we have a, you know, a tremendous amount of, I guess over the next year, developments still to play out.
But curious just as your sort of baseline operating assumption as, because obviously HCA is a company that looks out more than one year in terms of your planning process. How are you approaching thinking about 2026 for the exchanges? Are you assuming that the enhanced subsidies will stay fully intact? Do you assume that there will be some type of reduction, but you know, still maybe remain, you know, at some level higher than prior to the increases that we saw in the American Rescue Plan? Or more likely, you probably have several different scenarios that you're gaming out, right? And then sort of having contingencies around each of those.
But I mean, clearly, if you think about us, like any other healthcare provider right now, our focus is on working through getting the enhanced premium tax credits, on the exchanges extended, or continued in any way possible, right? So I think that's the key. Our focus right now is working with a coalition of health insurance companies and providers, to advocate for that. I mean, and the way I think about it is this is, you know, these are voters that, I don't think, would appreciate getting a tax increase, you know, right before the mid-year election. And so, you know, our view of this is that this has been really important to increase coverage in the marketplaces.
So we're going to advocate heavily to try to get the Premium Tax Credits that were enhanced through the, you know, during the COVID timeline, further extended, or at least extended in some modified way. You know, that's our first focus. Until we get a sense of that, it's pretty hard to really estimate potential impact. But you know, if you think about what would happen if the Premium Tax Credits were to sunset or be reduced significantly, you know, the modeling assumptions that we're working through, that I'm sure you guys are as well, is you know, how many people stay on the exchanges and drop down a metal and go from silver to bronze, for example? I think there'll be a fair amount of that. There will be individuals that will go back to employee-sponsored insurance coverage.
There'll be, there'll be some of that, and then there'll be folks that end up uninsured, right? And so, we're, we're still studying that, but until we really get a better sense for the potentials of getting an extension of the enhanced Premium Tax Credits, it's going to be difficult to, to understand what the impact is on the backside. So our focus right now is really focused on working through a coalition of, of partners to try to advocate for that. And, you know, I think again, you take, take our big states, you know, these are states that have benefited mightily from the healthcare exchanges. And so, you know, I think, we're going to have some receptive audiences to at least make it part of the conversation.
The last thing I'll say is, if you think about kind of the way the timing of this lines up, the individual tax cuts also sunset at the end of 2025, from the original Trump term. And so it is, I think the timing is interesting that both of these key programs sunset at the same time, and you're dealing with, you know, the really thin margins in the House and Senate. So we're going to be advocating for a deal that kind of addresses both at the same time. And we'll see, you know, what pops out of this, but it's still early, and that's how we're thinking about it.
Got it. And around that, obviously, it's going to be a big year around the tax, the tax program, updates, extensions. I assume there's going to be a lot of jockeying around that. And certainly the enhanced APTs are going to be right in the middle of that conversation around how are you thinking about, I guess, some of the other programs, you know, healthcare programs and how they may interface as well, you know, into this conversation? Feels like certainly publicly Trump and his crew have you know spoken pretty firmly around wanting to protect Medicare and not you know go there as a source of funds. They definitely have been sort of less, I would say, committed around Medicaid, you know, as a potential pay-for. You know, how are you thinking about that?
I guess, is that going to be something that HCA is going to be looking to advocate for in terms of, you know, trying to protect both programs? Or do you think that from a, you know, a pay-for perspective, that there is more risk around Medicaid, you know, not necessarily being cut, but, you know, the way the budgeting works, you know, that a freeze or a slower rate of growth can turn out to be a, a pay-for too? So I guess is there a baseline assumption and then how, from an advocacy perspective, how you're thinking about the Medicaid side?
Well, you know, Medicaid is such an important program for the entire American healthcare system, you know, not just HCA in our states, but I think about the durability of things like supplemental payment programs. And I think that's one of the topics that you would include in your question, Scott. These are programs that have been in place for a long time. We have programs that are going on 15-20 years old. They've been supported and enhanced in both republican and democratic states, and they've been supported in both republican and democratic administrations. And so, you know, I and everything I can see would say that they're, you know, they're durable. They feel pretty durable to me.
And I also think about kind of what it would take to make massive structural changes to Medicaid, you know, either the base program or the FMAP percentage or supplemental payment programs. And, you know, getting legislation of that size and complexity through really thin margins in the House and Senate is going to be complicated. You know, passing legislation of that size is not easy. The other thing I think about when I think about Medicaid generally, and I just said this, but let's kind of double-click on it, is the importance of this to the safety net hospitals. So if you think about government-owned hospitals and the not-for-profits that exist out in the marketplace, they really heavily rely on both supplemental payment programs and on adequate Medicaid reimbursement.
And so changes that would be contemplated in that, in that world would affect the rest of the healthcare market significantly, on the provider side. It would, it would impact us too. But, you know, we have the, the margins and the operating scale to manage through disruptions like that in a way that, you know, broad swaths of the not-for-profit hospital community may not, which I think, you know, also gives a little bit of support to, you know, the, the probability of massive structural changes to Medicaid or to supplemental payment programs. So, there's always risk, and we're watching it carefully, and I would never describe any situation as being completely risk-free for things like big Medicaid reimbursement changes. But I think the risk of that are lower than some of the other changes that we've talked about. And then we'll see, right?
Again, you know, I think we're still learning both from the nominees and from the Trump administration of what their priorities are going to be, and so we'll have to all watch it together.
Yeah. And I would, I personally largely agree on the state supplemental side on the Medicaid. I think that it's often overlooked, or basically how purple, you know, those supplemental programs have been when you look at, you know, a lot of those programs really gained momentum during the first Trump administration. You know, we've seen clearly this is the way that, you know, red state governors get an opportunity to cultivate and craft their Medicaid programs to have more of a look and feel of how they want those programs to be operated. So, you know, I think there's, from the bottom up, there's probably going to be a lot of support. Obviously, overall, the question's going to be just, you know, do they just sort of have a big round number, right, around Medicaid more broadly?
We'll see. Yeah. I, you know, again, I think the risk on this side are less than others, but everything's at play. You know, the other thing about supplemental payments I think are important, and you guys get this, but the other reason I think that there's been a lot of support in this world is that the provider community participates. So remember that, you know, we incur a lot of expenses to participate and help fund the Medicaid supplemental payment program, and those expenses show up in our operating costs, not as a deduction to revenue, and so when we go to support and work with a state to enhance a supplemental payment program, it always involves the provider community participating through provider taxes and other sources of expense that helps, you know, fund that federal matching.
So, you know, I think that's the other thing that the republican states have appreciated is that, you know, the base funding comes from the provider community to participate. So it's, I think it also speaks to the durability.
Sure. Sure. And just on the exchanges, I wanted to ask, I guess, more of a sort of near-term, sort of, question just on trends and again sort of using your formal 2024 guidance as the framework for that and what would be implied around the Q4 . Just in general, I guess, sort of thinking about some of the against that sort of normal seasonality that we tend to see with the exchanges, obviously that is a program where you can have, you know, some meaningful utilization typically occur in the Q4 , just given the design and the deductibles that are often associated with that. And then implications from special enrollment periods as well, which have, you know, been pretty, pretty strong, you know, this year year to date in terms of enrollment that's come off of that.
So basically the question for you, Mike, is, you know, I guess embedded into your outlook, how are you thinking about exchange volumes, you know, this year relative to sort of the normal seasonality? Would you say that it's largely consistent with what we've seen in prior years? And, or, is there any nuance to that and anything that you've observed that would, you know, influence that thought process either to the positive or negative side?
Yeah. And as you know, Scott, we don't generally give comments about a quarter that we're in. So I'll stay away from that a bit. But you know, generally speaking, the hypothesis that we've been looking at through the first three quarters, and we've even discussed this in answers to questions in our calls, is whether or not on this exchange population, will we see a tick up in utilization in Q4 , as people kind of burn through their copays and deductibles, right? And we've seen that before in the commercial book, for sure. And you know, we'll all know the answer to that question in January when we're on our Q4 call. So we'll give everybody an update on what we saw related to Q4 on the exchanges.
And so we'll withhold for now in terms of an early look as it relates to, you know, our early observations for 2025 that we shared in our Q3 call. You know, what we said was that we do think exchange enrollment will be good next year and at that 8%-10% level. And that's part of one of the reasons why, you know, we had confidence to go ahead and give a bit of an early look on demand. And so, as you recall from a Q3 call, we said for next year that we think demand will be. Our volume growth will be a little higher than our long-term growth targets. You know, our long-term growth targets for volume are 2%-3%. And I think it'll be a bit over that at 3%-4%.
Part of that calculus is exchanges.
Got it. One other policy question I want to ask you about is site neutral payment proposals, and definitely seeing a sort of consistent, I would say, tempo of literature, you know, coming out. Even this week, there was another study that came out, you know, providing, I guess, some estimates around that. Can you bring us up to speed in terms of, to the extent that, you know, you've gathered intelligence, I guess, around some of the new players on the board, you know, that are coming in with the Trump administration, not necessarily sure if I remember Dr. Oz having talked about site neutral, for example, but just in general, maybe where the GOP tends to stand, you know, on that topic.
Just as we think about that sort of broader context that we've already talked about in terms of where the focus is going to be, clearly with the tax bill extenders being a major area of focus. I guess, you know, some of these vehicles, do you think that particular policy discussion gets folded into a 2025 conversation or maybe it's not clear that that's going to be a near-term priority?
Yeah, it's still pretty unclear. I mean, it is clearly a topic being discussed. So well aware, just like as you've noted, that there's definitely some discussion going on and has been for a while. I mean, site neutral is a topic that's been out there, you know, for a fair amount of time. This is connected to traditional Medicare reimbursement, right? So the idea here would be that you would take hospital outpatient reimbursement and make it equivalent to, you know, kind of freestanding outpatient reimbursement in some ways. It's. I think about it as a bit of a spectrum. And so on one side of the spectrum and the area that I think probably has had the most conversation are things like physician provider-based clinics and outpatient infusion sites.
And that version of site neutral, it's pretty immaterial to HCA, because of the way that we structure and operate our employee physician practices. We do not operate those as clinic departments of a hospital. And so we're not as exposed to that definition of site neutral as the idea gets extended further into like surgical procedures or other imaging type procedures. Then you know it becomes a little bit more material to HCA. And so we're going to advocate heavily you know against site neutral. I can assure you the not-for-profits and the big government loan and academic medical centers are going to be arguing heavily against site neutral. It impacts them significantly. But I put it as like a distant third or fourth on the universe of risk level.
I mean, I wouldn't say depending on how far into the spectrum it goes that it becomes no risk. There's certain we would certainly have some reimbursement implications if it goes super far into the list of procedures, but it's, you know, pretty far down the list of concerns at this point. And it's also, we got to figure out what comes out, and, you know, what do the various nominees and, again, the Trump kind of more detailed policy position look like at this point? We just don't know.
Understood, and then just I had one more question on the elections just as it relates more to some of the macroeconomic potential implications. Wanted to get your thinking on that. You know, two things in particular would be just, I guess, labor market sort of second derivative effects if the administration does move forward aggressively with the deportation, you know, plans and, you know, sort of how that potentially can sort of play into the labor market, in terms of if we do see, obviously millions of undocumented workers who are embedded into the workforce, you know, right now, to some level get sort of pulled out, so that would be the first question. And then from a, I guess, sort of a baseline, operating assumption or planning assumption around rates and rent interest rates, you know, clearly there's a range of scenarios that can play out.
I think the general view is that we've still got more cuts ahead, but then there's always the potential if the animal spirits really are ignited and we get, you know, accelerating economic growth. Does that change the calculation on interest rates for 2025? So basically those are two things I'm thinking about, but really just wanted to give you the floor to sort of talk about, you know, some of these broader economic, you know, implications potentially from the change in Washington.
When I think about the labor market, you know, we as in healthcare is a little bit unique in this way, although certainly it applied to other industries, but we're coming off, you know, a period of time of some of the most significant changes and stresses on a workforce that you know probably ever existed in U.S. healthcare as we went through the COVID pandemic. If you go back to early 2022, you know, we were spending upwards of 10% of total labor cost on contract labor, on premium labor. And that was a reflection of the staffing challenges and just the sheer number of nurses and other clinical resources that had left the workforce for hospitals.
And so, you know, over the last several years, HCA has put forth a really significant effort to, you know, to stabilize our clinical workforce in the field. And we've seen turnover. I'll use nursing turnover, but generally turnover come down now finally to even being below where it was before we went into the pandemic. We've seen significant enhancements in our ability to recruit workforce and the investments we've made in workforce development, things like the Galen School of Nursing. We're up to 20 campuses, you know, almost 20,000 students now. By 2028, we'll have 30 campuses of the Galen School of Nursing and almost 30,000 nursing students enrolled. The work we've done on graduate medical education for physicians, you know, we're up to almost 6,000 slots for residents as they graduate from medical school to come and get trained.
And so, we have been putting a lot of effort to really stabilize our workforce as we've kind of come off the COVID challenges and moved into, you know, the current day and into next year. And so, you know, I'm feeling good as I sit here today that, you know, we're in a fairly stable operating environment for labor today. To your point, if I think about the you know, maybe you'd call it the lower skill mixes, you know, the environmental service workers, the food nutrition service workers, the patient care techs and the like, I mean, that would be the segment of the population that you're talking about. Now, you know, obviously, we don't hire undocumented workers. So, you know, we would be, but it could affect the competition for the workforce. And we appreciate that.
It's an area that we've put a lot of time, energy, and effort now in terms of our ability to recruit and retain that workforce. I feel like we're a good employer, with good benefits for that workforce, so you know, I think that on the margin, I feel pretty good about where we are today and as we're heading into 2025 about the stable nature of labor, and the work we've done to put ourselves in position to be an employer of choice, and so, it's not on the top of my list of worries right now, on the workforce side, you know, on kind of the growth of the economy and maybe even secondarily what happens to interest rates.
I mean, you know, healthcare hospitals have a little bit of interesting ups and downs, depending on what's going on with the economy. You know, we, on one hand, during kind of recessionary periods, we have a bit of safety effect in place. But in growth markets, what we tend to see is unemployment go down and coverage get expanded. So you just, you know, I think if the economy gets into a growth cycle as you indicated, then, you know, that is supportive of coverage. And we're in a good spot today on coverage. You know, we're, I think, in our markets at least, which, you know, it's probably important to highlight. I mean, we're in 44 really good markets in the southeast and the southwest.
The markets are urban, sub-urban markets that have above average population growth and pretty strong economies. I mean, we're very fortunate of where we operate and the strength of those economies. And so, you know, if the economic output improves, I view that as being positive to support coverage, and, you know, coverage supports demand, and getting paid for demand, so I see that as a positive thing for HCA. You know, if interest rates go up, then we would be dealing with the debt side, and so, you know, I mean, I feel really good about where our balance sheet is, our leverage ratios and the like.
And so, you know, I think coming into 2025, we're in a good spot, from a balance sheet perspective and ready to navigate, whatever happens, in this new economy and we'll see.
Great. I'm going to shift away to some other topics, but maybe let's take a pause here. If anybody had any questions on the elections or some of these macro topics before we move on. And then of course, if you do have something pop up, raise your hand and we'll get to you. All right. Why don't we sort of move over to, maybe we'll sort of frame it around the hurricane recovery. You know, probably just want to make a comment first that, you know, clearly there's going to be things that happen that are going to affect HCA, you know, in any given year, that are out of your control.
I think one thing you don't emphasize is just that, you know, the track record that HCA does have in sort of, you know, recovering, addressing and then recovering quickly from these types of circumstances is, has always been, you know, historically quite strong and has, as historically we also provided investors with a window of opportunity, when you see the stock react in the short term. You know, again, in any given years, pro fees and Valesco would be a good example for last year of, you know, some initial, you know, sort of impacts that you had to work through and then quickly got back on the recovery trajectory.
Wanted to get an update from you, obviously not trying to, you know, sort of circumvent, you know, sort of getting, sort of asking about the quarter, but, you know, clearly from where we last spoke on the earnings call, you've been implementing some of your processes around recovering from the hurricanes to the extent that you can maybe give us an update on sort of what areas, you know, have been, sort of in flight, in terms of recovery, execution, you know, more recently, sort of bring us up to speed on how things have been going. And then as we think about, you know, the balance of this year, you know, what are going to be those sort of key, I guess sort of initiatives that you're going to be looking to execute upon.
So thank you. I mean, I will say, I mean, I've been with HCA 28 years. So, and then I spent, you know, probably 10 years of my career in Florida, right? So I've lived through a fair number of hurricanes. And HCA's capabilities through our emergency operation command centers, our supply chain, our plant operations capabilities are really impressive, even for someone who's inside. And the focus that we put on making sure that we help the communities that we have the privilege of serving, of preparing for storms, dealing with during the storm and then recovering from storms is very impressive. And so I would echo your statement even from an inside perspective. I'm really proud of the work that our teams have done in North Carolina and Florida to help our patients, our colleagues, and our communities deal with these challenges.
We're on track, you know, with the work to repair. I'll start in Florida. I think you'll recall from our Q3 discussion that we had one hospital that got damaged pretty significantly during Hurricane Milton. It's in the Tampa area, just kind of halfway between Clearwater and St. Petersburg. It's called Largo Medical Center. We've had literally hundreds of contractors on site repairing that facility. The main emergency room has reopened now. And we will have the hospital reopen for inpatient care before the end of the year, which was our target. Then we expect that market and that facility to recover as we kind of go through 2025, which will be great.
In North Carolina, you know, our facilities actually weren't heavily damaged, but the communities were seriously impacted, with you know, mostly the flooding from the rain events and all the flooding that occurred in Western North Carolina from that. There was a lot of wind damage too that impacted that area. And so, you know, given the topography in that community, I do think that there will be lingering effects of the hurricane in there in the recovery of that community and, you know, just from a healthcare perspective, the recovery of demand in that market that will probably linger into 2025. And so, that's what our projections are. As I mentioned on the call, you know, the effect of that is this.
We think that the recovery in Largo and in Florida will largely help offset the lingering effects from North Carolina, and so I think, you know, on the financial picture, the recovery in Florida will offset the year-over-year earnings declines that we probably would expect from North Carolina, and so that's how I think about 2025 from those regards. Then just the only other note I would make financially, and we mentioned this on the call as well, is that all the numbers we provided for both the Q4 impact, Q3 impact, and kind of the early look for next year do not include insurance recoveries, and so, you know, these are going to be pretty complicated claims. I think insurance recoveries will probably more be in 2026 and not in 2025.
Just a note on insurance recoveries, but the teams are working hard, you know, in supporting our communities and so far so good.
Okay. Got it. Want to talk about a couple of the key sort of underlying trends that we've been seeing that have been impacting the sector and that you know need to execute your business against or within, so the first would just be around, you know, that long-term sort of shift from inpatient to outpatient and just the tempo, you know, of that in terms of, you know, as we think about basically what you've been seeing in 2024 year to date. Obviously there's many different factors that play into that. You know, we did have, for example, in 2023, there were some of the CMS coverage determinations that had, you know, bolstered some of the, the ASC, you know, type, you know, underlying, sort of volume shifts.
You know, curious in terms of how you see that sort of from that, you know, anything that you would call out, in terms of being, you know, more unique to 2024 or thinking out to 2025, that could either, you know, accelerate, maintain, or decelerate that, that trend relative to, you know, what we've been seeing as sort of the average run rate of that, you know, playing out for literally 20 years now.
Yeah, and you know, the death of a hospital structure has been predicted for a long time and it hadn't really happened, you know, value-based care, except managed care, et cetera, et cetera. I've been really, you know, encouraged about just the long-term durability of inpatient demand. I think we highlighted that in our investor day last year in October and you know, clearly 2024 continues to show that we tend to have about the same level of annualized revenue growth on inpatient and outpatient, is what we see is that we're a hospital-centric healthcare system. So we're a little different than some of the other competitors that focus more on outpatient. We have 26, a little over 2,600 sites of care. So we have a, you know, a fair number of outpatient sites of care, per hospital, if you will.
We believe in a network model. You'll see us when we're in a community. Nashville is a great example of this. We'll have acute care hospitals kind of spread around a community typically. We'll have outpatient sites of care where we try to meet the patient where they are, things like physician clinics and urgent care centers and ambulatory surgery centers, freestanding emergency rooms. You'll see us kind of go through a market and place assets where they're needed, where there's demand for those services broadly across the market with this idea of having a network of care sites. We're certainly interested and we see good growth on outpatient in our communities and in our volume picture.
But between our in-market network structure and the way that we provide service to the outreach markets, the surrounding areas, kind of the rural healthcare markets and our ability to bring volume in from those markets. You know, we suspect that both inpatient and outpatient demand, given what we're seeing for the demand of healthcare services, are durable. So you know, if you think about the 2%-3% long-term guide in volume growth and the, you know, fairly significant volume growth that we've seen this year, the population growth in our markets, the network strategies and our annual capital investments that we make into those networks allow us to capture that population growth, take market share and show volume growth each year.
You know, if you think about kind of our early observations for 2025, Scott, it's what gave us confidence that, you know, we do think we'll see a continued bit of elevation in demand for 2025. So we kind of slated it as probably between 3%-4% growth next year. You've already mentioned healthcare exchanges. That's a piece of that story as well. Enrollment growth, kind of interesting. We're in a bit of a period of time right now where there's a bit of an elevated move to Medicare. If you look at the number of people forecasted to age into the Medicare program in 2025 and 2026, it's at a little bit of a higher rate because of the retiring of the baby boomers. So that's another piece of that.
And then, if you just put it in the macro view of things, you know, the aging of the population, the persistence of chronic diseases and the like, you know, just continues to show that even as cases, the lower acuity cases kind of leave inpatient and go to outpatient, they're kind of getting backfilled with more acuity. And so we're seeing, you know, pretty durable growth in our acuity. We do a lot of work to support that with service line development in our markets with cardiac programs and neurosciences and the like, cancer and the like. But the combination of how we operate, our capital investments into our markets, and our growth and strategic plans allow us, I think, to be confident that we're seeing both demand for healthcare services and our ability to service that.
Perfect. Yeah. That's exactly it into my follow-up question. 'Cause obviously when I was referencing that sort of historical shift from inpatient to outpatient, you're not a passive bystander. And if anything, it frees up capacity to, to provide more of the higher acuity services and, and optimize, you know, your service lines. Had a couple of questions around this. I wanted to ask you about, I guess the, the first one would be just around that sort of overall trend of acuity case mix, you know, that we've, it feels like it's been, you know, on a, on a steady sort of upward climb. Maybe can you talk about sort of, you know, year to date, how that trend, you know, has it been sort of a consistent tempo to it over the course of the year?
Have you seen any type of, you know, intra-year nuances to that? And then within that initial framework that you provided for 2025, what the baseline assumptions are around that acuity and case mix assumption?
Yeah. So far this year, we're up just short of 50 basis points on our Case Mix Index. On the inpatient side, I think it's 40 basis points. It's in that zone. Q3 was 50 basis points. It's been pretty consistent. You know, we've seen, if you think about kind of before COVID to after COVID, you know, we've seen good acuity growth over the last five years. And we saw good acuity growth, you know, kind of the 10 years ending 2023. You again, if you go back to the presentations at the investor day, you know, we talked about what we have seen over the last decade related to acuity growth, you know, largely being driven by two factors as I see it. One is factors we control, which is our investments in high acuity services, right?
So we work every year to both deepen and broaden our service lines in the markets we serve. So if you think about deepening them, we take things like basic cardiac programs in our hospitals and then we add to our ability to provide those services. Think about going from, you know, a cath lab program to an open heart program to adding TAVR to adding electrophysiology, structural heart and the like. So over time we look to deepen the service line capabilities in our hospitals so that we can provide care to the patients who need it in our marketplaces. And then we also broaden our service line depth. So we'll take feeder hospitals that are out in suburbs and as those suburbs continue to grow in population, we'll start adding additional service line capabilities to broader parts of the marketplace.
And so, this long-term strategy of HCA to be hospital centric and to invest in our service line capabilities allow us to grow our acuity of the services we offer over time. And I think that will continue. The second thing I think you're seeing is the macro factors. And we've mentioned this a little bit, but you know, you're seeing over time, lower acuity cases kind of go from inpatient to hospital-based outpatient and in some cases out to surgery centers and physician offices. But then those services get replaced with higher acuity services over time. The age of the population, the persistence of chronic diseases, people living a longer time with chronic diseases, you know, kind of, has shown over the last many years.
We actually had a slide in the investor day deck that showed the various levels of acuity and what's forecasted on demand. There's pretty strong demand forecasts for the higher acuity services over the coming years. And so, you know, I think the combination of our service line strategies coupled with the macro factors that we see in the marketplace tells me that I think acuity will continue to increase at a reasonable rate into the future. And that would be our predictions. And you know, this year it call it 30-50 basis points of case mix index growth, I think fits that pattern.
Got it. And wanted to ask about one disease state in particular, which definitely feels like there's been a number of not only anecdotal, but just firm sort of data, which is oncology. And obviously you have HCA probably has a perspective on this that's unmatched in terms of what you're seeing out there, even into the Q3 , you know, whether it's payers, whether it's providers sort of talking about trends around that certainly feels like there's maybe this is part of that post-COVID type dynamic.
Maybe it's just those demographics that we're talking about with the aging population, but definitely be very interested if you could provide us with an update on, you know, sort of what the underlying trends are that you've been seeing around oncology, across your markets and whether it does feel like there's been an incremental step up, I guess in incidence rates, in 2024 or is it more, you know, more overall, I guess, not as observable to you?
Well, you know, it's interesting when I think about our service line volume, you know, kind of trends. We have seen growth in volume in our oncology service lines, both on inpatient and outpatient. You know, definitely in the surgical side, that's more inpatient really, but it's outpatient too. But it's consistent with pretty deep and broad demand growth across our service lines. I mean, so yes, we have seen growth in demand for cancer services in our communities. But when I look across, you know, the service lines that we track on both the inpatient and outpatient side, we've seen growth in demand and volume growth across almost all of them. I mean, there's really only a couple of service lines that are off a little bit.
One would be outpatient surgery that we've talked about broadly, which as we've said, you know, it's really kind of reflective more of Medicaid and self-pay volumes being down in that particular service line, outpatient surgeries, and then behavioral health on the inpatient side is down a bit. We did that a little bit to ourselves and we converted several units in our hospitals from behavioral health back to Med-Surg because we needed more Med-Surg capacity. So when I look at the inpatient behavioral health volumes being down a bit, it's really reflective of a bed transfer, you know, from behavioral health to Med-Surg. But other than that, we've seen, you know, pretty strong demand for healthcare services across a wide swath of our service lines, certainly including cancer.
Yeah, so the answer is yes, but I don't know that it's outsized versus other components of the service lines or service offerings that we see.
Got it. Unfortunately for me, it seems like that 45 minutes always goes too fast, but it looks like we're out of time here. I wanna thank Mike and Frank and the HCA team for joining us at the conference today. Really appreciate it.
Absolutely. Thanks, Scott. Thanks everybody.