Good evening, this is John Ransom. Welcome to the first day of the Raymond James Conference. Here, making their inaugural appearance at the great IIC, is the management team of Oscar, a stock we picked up about a year ago, and it's been fun. So this is going to be a hybrid format. Scott's going to take us through the high level, and I have a bunch of really smart questions. So we'll go from there. Scott, take it away.
I appreciate that. So it's a pleasure to introduce Oscar to this group. I think we like to think of Oscar as still a late-stage startup. We launched the company about 12 years ago with a mission to bring technology to the healthcare marketplace. We are focused on serving the Affordable Care Act as the majority of our business. We are laser-focused on creating a unique and amazing member experience. That's kind of the hallmark of the company, is starting with the member. This year, we've got around 1.8 million members in the ACA. We've grown pretty significantly over the last number of years, and that's also been the trend in the ACA Marketplace. The ACA Marketplace now has over 24 million people that are in those markets. So it's become a large and important part of the country's health insurance marketplace.
And then I would say that we believe that the ACA has some unique advantages that it brings. One is it's got the lowest cost trends of any of the health insurance marketplaces, and that's because of its large risk pool. And we think that there's some new products that are going to bring more individuals into the ACA Marketplace. The most important of that is called ICHRA, which is an Individual Contribution Health Reimbursement Account, which think of it as a 401(k) for health insurance, where instead of the employer picking who provides you your health coverage, the employer puts money into a plan, and then you go on to the ACA exchange and you pick your own healthcare provider. And we believe that this is going to be a marketplace that has a meaningful opportunity for significant growth.
There's around 75 million people that are in small business or middle-market-sized companies that we believe are ripe to move into this ICHRA type of program. We think it's going to be a catalyst for a significant opportunity for growth for the marketplace and for our company. Kind of thinking about where the company's been, where we're going, 2024 was the best year in Oscar's history. In 2023, we got our insurance companies to be profitable. In 2024, we got the total company to be profitable on an adjusted EBITDA basis, and we also delivered profitable net income. So some really important milestones. In 2024, we also grew our revenue at 56%. Usually, in healthcare revenue growth at that level, results in some leakiness in your medical expenses, and we were thrilled to be able to have very high growth with very stable MLRs. That's the Medical Loss Ratio.
Our medical expenses were in line, utilization was in line with what we expected. That's what we think we can bring to this industry is above-market growth and terrific bottom-line performance, which is a catalyst for strong valuation. Going forward, we think about 2025 as a year where we're likely to see growth go from 56% last year to around 23% in 2025. That's still well above industry averages in terms of market expansion. We think we're going to be able to generate positive bottom-line performance both on an adjusted EBITDA basis, on an EBIT basis, and importantly, on a net income, GAAP net income basis. We're looking to take big leaps forward in 2025. That really sets us up well for the future.
We've given long-term guidance that the company believes by 2027, we will have grown our revenues at a CAGR of 20% from the beginning of 2024 through to 2027. We're on pace to continue to grow in a strong way, which will help us achieve our long-term target. We think that we can generate $2.25 of EPS in 2027, and that would be on the back of a 5% operating margin. So those are the long-term targets that we're running the firm to try to achieve, and we're well-positioned to deliver on those. So we're excited to have the conversation, John, and I'll turn it over to you.
Oh, God, I got to come up with questions now. So in 2024, CMS, and kind of surprisingly to us, under Biden, made a bunch of program integrity changes administratively. So maybe describe those in layman's terms. And the corollary question is, going into 2025, there was a lot of controversy about how fast the market would grow. And there were people, market participants, who thought the market might actually shrink because of some of these changes. We would note on paper the market grew 13%, but maybe when you screen out the non-pays, it might grow a single-digit or something. But just talk about some of these changes, like I said, in layman's terms, and then why you think they didn't quite have the bite on growth that others did.
A couple of things that happened. In the middle of 2024, CMS put in a rule that restricted the ability for brokers, which this is a broker-dominated marketplace, to move someone who was in the ACA from one carrier to another carrier without explicit permission from that individual. That really restricted kind of movement inside of the ACA. We think that was a very good thing in terms of removing the risk that someone could be moved from one plan to another without their permission. That took effect middle of the year, really didn't slow down market growth, but slowed probably the transfer of members from one plan to another.
Then at the end of 2024 and going into Open Enrollment, if you don't know much about the Affordable Care Act marketplace, most of the membership growth occurs on an annual cycle during Open Enrollment, which happens at the tail end of the year. And going into Open Enrollment, CMS put in some additional requirements that you've got to put in for everyone who goes into that marketplace, you have to have an active Social Security number. They later updated that to say it could be a Social Security number or a valid Alien Identification Number. All of that driven towards trying to ensure that the people who were in that marketplace were legitimately there because this is a deeply subsidized marketplace.
And so they needed the information that they could use to then go back and validate people's stated incomes because the way that subsidies work in this marketplace is you give the government an estimate of what your next year earnings will be, and then you come back and reconcile after when you file your tax return, you reconcile that to your estimate. And if you're off by significant amounts, you may have to, the individual may have to do a true-up to pay a portion of that, the premium. So that whole process is called File and Reconcile. That's the last thing that's happened is that in coming between 2024 and 2025, CMS has started to, for a while, they were really not checking to make sure that people's stated income that they turned in was reconciled to what they put on their tax return.
They've started to do that now in force. The first leg of that population, we got notified at the end of 2024 who was being disenrolled because they had failed to File and Reconcile. There's another population that we think will be taken off of our books in the April timeframe. We know what the number is. It's a small portion of our total membership, and when I say small, I mean insignificantly small, and so when I look at all these overall set of rules, I think it's actually a really good thing to create stability and transparency into the ACA Marketplace. We think that net-net, it might be challenging in a short period of time as people get accustomed to the new rules, but over time, we think it's better to have a high integrity set of rules.
You had mentioned last year, one of our conversations, that the company was also intentionally up-tiering its list of brokers and that that really was kind of the first check to make sure you're not allowed to churn. Just talk about your process of broker selection and what you did last year to up-tier.
So in our marketplace, the government through CMS is the one who validates whether or not someone, an individual, meets all of the requirements to be on the exchange. That means income validation. That means that they aren't covered by other insurers. And so we don't do that. That is in the domain of CMS. What we do is to make sure that the brokers that we're doing business with are bringing us legitimate members who are appropriate individuals to be on the exchanges. And we do that through a variety of analytical procedures to check for things like, did you just enroll 20 people and they all live at the same address? Did you enroll a bunch of people the day before they all went into the hospital for a rehabilitation program?
We look for patterns that would suggest that the broker is violating the rules of the exchange, and then we report those brokers to CMS. That is certainly the edge case. The vast majority of the brokers that we do business with, we've had long relationships with. They are high integrity organizations. And so I would say that our energy's increased because the number of brokers using call centers increased. There's inherently, I think, a higher risk of call centers not having either the right training or not following all the protocols that are in place. So we have higher screening and checks on brokers that are using call centers because for us, there's no benefit to having an inappropriate member who later gets disenrolled.
We try very hard to ensure that we do a check through every means that we can to validate that brokers are bringing us appropriate members.
In your long-term guide, you run the numbers. SEC school math would say that you're about $0.25 short. You'd need another point of margin to get to the $2.25. So as we think about the different ways to get there between G&A, share buybacks, other things, how should we think about that small gap?
We look at that being a matrix of decisions. So our target is to get to 225, right? And Mark Bertolini, our CEO, has a track record of not missing targets. And I can tell you that Mark and I have every Monday morning conversation about where are we on all of our strategic plans. We meet as a leadership team once every month to go through the strategic plans, all the things that we need to deliver on that plan, where we are against all those initiatives. And that is how Mark runs the company, his operating model that we use to ensure that we hit these targets. So I would say that getting to 225 is deliver the top-line growth, get our MLR to around 80, get our admin expense ratio in the 15%-16% range.
And then along the way, we'll do some other things to improve what would be the outstanding share count that is out there. We think there's some opportunities to do things around the margins to decrease the effect of stock compensation to employees. But all those things will be the levers to make sure that we deliver on that 225.
The 16% target, 5% total target, that was done pre-AI, and you guys have been very public about we're running a number of AI. The fixed variable commentary would imply the fix and spending went up quite a bit this year. But just talk about what kind of returns you expect. And just again, in layman's terms, when an insurance company applies AI, how does that not turn into some hellish process where you can't talk to a human when you get a claim denied? What do you do behind the scenes, but also make the user experience either neutral or positive?
Remember, I started off by saying that our company is laser-focused on member experience. That is kind of the lens that we put on everything we do is how do we improve the experience of our members. And with respect to AI, we are using AI to, number one, make our call center agents more efficient, right? So yes, we're doing the standard AI things like push one if you want to understand what your balance due is.
We've got all those standard processes that we use, but we're also trying to do things like give our call center agents AI-generated scripting that says if someone just asked for, "Hey, I want to know the results of a test that I had run," instead of that call center agent having to go through and read for the first time the transcript of that test and synthesize that for a member, AI is reading that test and generating a short, "Here's the answer to what's the results." And we're finding opportunities like that where it sounds like a small step, but these are the things that take these agents a lot of time. You spend a lot of time. And so the member's sitting there waiting and listening, and it's inconvenient for them.
So when we can synthesize the types of communications that we know routinely come in, we can do them in much quicker succession. That means fewer call service people, or they spend their time in other high-value ways. And so that's an example. There's a laundry list of these things that we're doing. What we're trying to do is to make our people more efficient versus less efficient. We are trying to automate to eliminate where we can human intervention. And as you mentioned, some of our fixed costs are going up in 2025, and that's in part because we're leaning in to make some investments to help us for the push to get to 5%. And so we'll do that on the back of technology, all of which we have line of sight into the steps that we have to take.
I think we can get rid of paper EOBs.
Oh, God, I hope so. In an industry that uses fax machines, right there, we should all give ourselves an F. But getting to digital scorecard for health where we all share records digitally, where explanations of benefits is digitally, where all the claims data between insurers and the providers is digital, that has got to happen. And it can't happen soon enough, but we still are stuck in a world where the weakest link is managing how all of this happens. And so we do still have a lot of manual types of communication.
I wonder what the average age is of a fax machine salesman. It's probably old as me, right?
Yeah.
Who would want to be a salesman?
Certainly, the average age of their product is getting really, really, really old.
Going back to your analyst day and the 20%, at the time, you correctly predicted the exchange market at 2024, and I think you said it would go to 21 million in the case of enhanced subsidies going away, so just a couple of questions. Are you still thinking that's the case, number one, and then number two, just this is very qualitative, but what's the latest? Everybody's laser-focused on this enhanced subsidy issue. What's the latest dynamic with people you're talking to inside D.C.?
Sure. So when we did our investor day in the middle of 2024, we said that we expected 2025 that the ACA market would grow by something in the order of 15%. It grew 13%. And so we were pretty pleased with that performance. Our growth has been consistent with kind of exceeding the growth of the market, which is always what we're after. So we feel great about that. We think it's a good jump-off point for the future. We gave long-term guidance that presumed that enhanced subsidies went away. And we did that not because we believed that they would go away, but we wanted to give investors the ability to underwrite the worst-case scenario. And that's what we basically are running the company to ensure that if enhanced subsidies go away, we'll still hit those long-term targets that I described in 2027.
Where are enhanced subsidies going to go? I don't know that we yet have a point of view of where the final solution is. I do think that we see lots of reasons for optimism about some form of continuation of enhanced subsidies. It's just a fact that 77% of the ACA is now in red states. There's a really good reason for those states to want to find a solution that includes some form of subsidies. And we think that both parties should look at this as an opportunity. The uninsured rate in the United States is currently as low as it's been. It just doesn't make sense to go backwards on that. So we need to find a solution as a country that allows these people to continue to have insurance.
We believe that there is room for negotiation, and we're optimistic about kind of the chatter we're hearing that both sides think that this is an issue where they might be able to find some common ground.
So the discussion always gets broad and then goes very specific. Do you think the people you're talking to are enough in the weeds to know the problem at the 100%-200% level for sure? And maybe that's what 60% of the ACA, but is there some appreciation that maybe one of the pay-for would be, we look at the higher end of this, but focus our attention and resources on that cohort?
I think there is certainly maybe a level down from the top of some of these organizations that are deeply aware of kind of the structural issues. There's plenty of think tanks that understand kind of the dynamics. And if you understand how the enhanced subsidies work, before the American Rescue Plan, subsidies were capped out at 400, and that's 400% of the Federal Poverty Level, and then increased as you went towards 100%. If you're below 100%, you basically qualify for Medicaid. And so the subsidies with the American Rescue Plan were increased. So below 400, the amount of subsidy increased. And then above 400, they allowed for subsidies going up into higher levels of income. So there's certainly dialogue around, do you cap the top end? The majority of our members tend to be in the lower FPL levels.
So our exposure is primarily around what happens if there's a change in subsidies in the more subsidized buckets. But from everything we hear, the direction of travel is there's probably some ask for everyone to pay something. So going from lots of plans where people pay zero premium, maybe they pay a dollar. I don't know. There's some desire to have some personal contribution on behalf of members. We think that there's a level where that can still be affordable. And then there's the potential, as you say, for capping, kind of going back to the original design of subsidies where at a certain point you cap that there's no subsidies above that level. So both of those, I think, are on the table.
All right. So we're getting a little bit in the weeds because I'm running out of questions, but we'll keep going. So just one of the frustrations we have is the CMS data doesn't line up with Open Enrollment, so we're always kind of trying to guess at things. So just reading between the lines, you grew a ton. As of 12/31, you grew a ton in Georgia, but then Georgia, you lost your no-premium plan. And then you talk about 200,000 people dropping from the 2 million to 1.8 million. Should we assume that a good chunk of those might be in Georgia that were former no-premium, now there's some premium, and you haven't been able to get in touch with them?
You are really getting into the weeds. I agree.
I am. Thank you. Is that a compliment?
Certainly, when you have this marketplace, if you're the first or second lowest-priced Silver plan, you qualify for something called a cost-sharing reduction plan. You become the market for that cost-sharing reduction, which basically means that there's a certain actuarial value where people who get that plan pay no premium and they have a very low deductible. And so that has been a nice catalyst. If you're in that position, you typically have outsized growth in that marketplace. We had that last year in Georgia. We don't have that this year. As part of the when you have that, if you retain a member who last year was on a $0 plan and they haven't been paying attention and they get brought over, you retain that member. Because once a member's on your roll, they have to take an action to change their plan, right?
And so if that member stayed on our plan and all of a sudden was expected to make a payment and they don't know that they were to make a payment because they haven't been paying, those are the kinds of people who ultimately end up becoming basically a non-payer, and they get disenrolled after a portion of time. So at the beginning of this year, we looked at what's the risk of those non-payers to the company. And so we told the market the number of people who are paying, who've made their first payment, just so there was no question about, is there a risk that you could see some people who aren't going to make their first payment? And so we guided to our revenue guidance is based on the number of paying members we had as of February 1st, which was 1.8 million.
We actually had close to 2 million, 1.98 million members who actually were, you'll hear this industry term, effectuated, which are people who passed the CMS checks and have been assigned to Oscar as potential members. But not all those effectuated members ultimately make a payment. So we believe that it was better to tell you what's the paying membership. Again, that's 1.8 million members. We expect for 2025 that that membership's going to be pretty much static at 1.8 throughout the year. And that's the basis of our revenue guidance.
So look, I know ICHRA is not a material number of members, but on paper, it just looks fantastic. But it's been a little slow, not so much Oscar, but just the marketplace. What do you think needs to happen to get ICHRA to be bigger than a breadbox? Do you need a regulatory change, or do you just need more time in the market to educate people? There need to be support companies. What do you think needs to happen?
I think that ICHRA, without any additional help, is going to be a force. It could be accelerated with some potential tax breaks, with some permanency into right now. ICHRA exists in regulation, so getting it into law might be another step in the right direction. Look, ICHRA. I don't know how many of you know what ICHRA stands for. I know that it took me six months of hearing the damn term to know what ICHRA stood for, and it's not well. The whole process of what is ICHRA is not well defined, and so getting the more common sense language involved in this product. We think that the market doubled last year. Our book doubled as well. We think that the opportunity, as I talked about in my opening remarks, there's 75 million people that are in middle market and small group plans today.
And all those people are prime targets for ICHRA. And so we think there's some nascent infrastructure that exists on the banking side of ICHRA, which is how do you take money from the employer, create an account for the employee, and pay their binder premium every month. That now seems to be working really well. We think there's an evolution that's still going on to help the employee in selecting an ICHRA plan or an ACA plan that they can use their premium to fund. So we're incredibly optimistic that a plan that can deliver lower annual price increases, right? The ACA's increased at something like in the mid-single digits of annual price increases versus commercial plans that have been in the low double digits, right? That's just an obvious non-sustainable difference.
Me as a CFO, I would be looking for how do I get to the other side of this thing where I can take advantage of the single-digit price increase. Then the other powerful thing about the ICHRA market is your employees, instead of your plan being underwritten to the 50 people that work in your company, those people get underwritten against a 24 million member base. It really disperses the risk, and you're able to have a much more stable and lower price experience. We think that the infrastructure is coming along. We think that awareness is coming along. It may take a number of years for this market to really get its feet going, but we're feeling confident about the direction of travel.
I have an EBIT question, which is a good one. The HIX rule sitting at OMB, any speculation on what's in that? You'll make Chris very excited back there if you have some scoop.
I don't. I don't. Unfortunately, they don't share that information with me.
Okay. Time for one question. Anybody?
Individual Contribution Health Reimbursement Account. Again, straight from the government.
Healthcare 401(k).
It basically is just like a 401(k). So it's moving from a defined benefit program to a 401(k) type program where it's funded, but you decide what to do with the funding.
All right. We'll see you guys in breakout.
See you later.