Morning. Welcome to Oscar Health 2026 Investor Day. It is great to see so many of you. I know it's conference season, so thank you for joining us this morning. We appreciate you taking the time. I'd also like to welcome everyone that's joining from the webcast this morning as well. Thank you for joining. For your reference, all the materials that we will present today will be available a little bit later this morning, and you can find that on our investor relations website at ir.oscarhealth.com. As a reminder, any remarks Oscar makes about the future constitute forward-looking statements within the meaning of the Safe Harbor Provisions under the Private Securities Litigation Reform Act of 1995.
Actual results may differ materially from those indicated by those forward-looking statements as a result of various important factors, including those discussed in our most recent annual report on Form 10-K and other filings with the SEC. These statements are based on our expectations as of today, and we specifically disclaim any obligation to update them. Okay, before we begin, I just want to hit on and briefly walk through today's agenda. First, Mark Bertolini, Oscar's Chief Executive Officer, will share our vision and strategy, including how we are building the premier consumer healthcare company. Following Mark, Scott Blackley, our Chief Financial Officer, will discuss our financial outlook, including our updated 2026 guidance and longer-term financial targets.
We'll then have a quick break, and when we come back into the room, Janet Liang, President of Oscar Insurance, will discuss how we are strengthening our leadership in the individual market. After Janet, Mario Schlosser, Oscar's Co-founder and advisor to the CEO, will discuss how Oscar's scalable technology and applied AI enables durable earnings power. That'll wrap up the presentations for the day. We'll ask all the presenters to come back up to the stage and we'll do a question and answer session. To close the meeting out, Mark will provide some final remarks, and for those in the room, we will have lunch available. We'd ask that you would stay for lunch if you can do that. So, good agenda for the morning. We're excited to get started. With that, it's my pleasure to introduce Oscar's Chief Executive Officer, Mark Bertolini.
Please welcome Mark Bertolini, Chief Executive Officer, to the stage.
Thank you, Chris. Good morning. Thank you for coming. It is always so nice to see so many smiling faces at an investor conference. You can try smiling. The information will come across a little better. We are going to discuss our vision and our strategy today, but I want to make a few comments about what strategy really means. Strategy is not buying an asset. Strategy is not coming up with a good idea. Strategy really is finding fundamental capabilities that differentiate the organization and applying those to unmet needs in the marketplace. The journey we have been on for the last 3.5 Years has been very much about creating those differentiating capabilities, those insights. We bought an asset along the way, but it was all part of having fundamental capabilities that meet upcoming changes in a market where unmet needs have not yet been met.
We are going to talk about that a little bit as we go through the discussion here. 50% of consumers feel that healthcare fails society's needs. We have $200 billion in active consumer medical debt across the U.S. today. Unacceptable, I would think, in the 21st century as a norm. Our mission is to empower consumers to build healthcare around them. They will drive innovations and better value and quality. The whole stream of consciousness here is to think about getting to a place where we can have consumers, through curated pricing, be able to make value-based decisions that matter to them, like every other piece of their household budget. Healthcare as number 1 is the only place where they cannot. They do not know what they are paying until they get a bill later on.
If we can create that ability in consumers, they will do the fundamental work longer term of reducing the cost and driving out high rents in the healthcare system, as they have done in every other market that they have had that opportunity. Our 2026 earnings, we raised them this morning to $600 million-$800 million. Our SG&A expense ratio is the same. We improved our MLR for the year based on what we are seeing in our underlying medical costs. Whoops, sorry. Wrong slide. First, sorry. Good stage direction. We have a deep bench. This is a gallery of rogues, but we have a deep bench, and we have the A team. The one thing I want to say about this group is that this group gets up every day thinking about this business. They are not worried about other parts of the business.
They are not worried about capital allocation between businesses. They are focused on the ACA, and that results in every employee in the organization being focused on the ACA. One of the amazing things I found when I joined the company in 2023 is every employee in this company is engaged in a mission to make healthcare better. We have employees that have been with us the whole way, and they are continuing to be involved. This leadership team is a pleasure to work with. They lead great people who every day work really hard. Now, guidance. Guidance is up $600 million-$800 million from $500 million-$700 million. Our SG&A ratio, same range. MLR has improved. $18.7 billion-$19 billion in revenue, not much change there as well.
But what it has done is it allowed us to make investments in other parts of the business, in the new stuff that is coming along. We will show you some numbers today. Scott will go through them in more detail. Those numbers for 2029 do not rely on a whole lot of what we do in the new businesses, but the investment in those new businesses is part of those projections. Those investments are the hard work that we need, because you never really show your work until you actually can prove it works. And so all of the investments that we have been making over the last three years, what we will make over the next three years, will prove to change the American healthcare marketplace and allow individuals to purchase their own healthcare the way they want. Three years ago, 2.5 years ago, we gave you these commitments.
At the time, in 2024, we had $9.2 billion in revenue and a 0.6% operating margin. Since then, we have had a 43% CAGR, which exceeded our 20% CAGR, and we have had 260- 360 basis point improvement, with a commitment, which we are reaffirming, of at least 5% in 2027. Here are our long-term key strategic objectives. To become the number one consumer preferred AI native carrier through our strategic ACA advantage. The issue around this point is, we are not spending billions of dollars like the rest of the industry, healthcare industry, rationalizing platforms and cleaning up our data. From the very beginning, this company built a platform that was single-threaded, cloud native, with one version of the truth, which has allowed us to implement AI at scale with significant bottom line results to the company.
Mario will come up a little bit later and talk a bit about that. Second, is to unlock the full potential of the individual market to support healthcare needs for all Americans. We do not believe that the ACA is the last place for this company to be. The TAM is not big enough. The market opportunities are not great enough. The competition would be too fierce. So our view is, that we need to continue to expand the market opportunity for individuals to have the same opportunity that people in the ACA have in having to pick their network, and also to pick their product. Then finally, build the leading healthcare marketplace to serve people's health and financial goals in a larger individual market. It means more than insurance. It means GLP-1s. It means all the supplements that people buy.
It means all the lifestyle things that people buy in order to impact their health and live a healthier life and enjoy life. That is what the Lucie Health Marketplace is all about, and I will show you some of the statistics around that a little bit later. So let us talk about the future of the consumer healthcare marketplace. The era of employer health insurance is ending. 94% of employers are looking for a new solution for their healthcare costs. I talked with a CEO of a large multi-state company with 40,000 full-time employees, and he says, "I cannot buy healthcare economically any longer. My rates are going up on a self-funded basis, double digit. There has to be a better solution." On top of that, we want to be able to build the leading payer agnostic marketplace for health benefits, products and services through Lucie Health Marketplace.
The secret behind what we built is not that we built it for us, we built it for everyone. We're making a market. Lucie, with all of our competitors engaged, all having access to the same technologies, including some of Oscar's technologies, think about the new +Oscar. They will be able to use those tools to compete in a marketplace, and they will pay rents on that capability. The Lucie Health Marketplace becomes a place where all competitors can build a broader market.
It takes me back to the early 80s when four friends of mine and I started an HMO in Detroit, and we got together with all the other HMOs and said, "How do we take all that business away from the big carriers who have all the money, all the distribution?" By the time, 10 years later, all those big carriers, other than Aetna, were out of the health insurance business, for all intents and purposes. This is our opportunity. Create the market for the better good of the whole industry and all Americans, and then compete within it. Currently today, the ACA market has a total TAM of 49 million individuals. There are 19 in the ACA, and there's still 30 million uninsured individuals. That's our target.
You can see the rest of it, and we'll talk about it as we progress through the presentation, but the opportunity goes to all 350 million Americans. The far right column is 100 million Americans in public programs. Today, we're already having conversation with state-based exchanges and governors about doing demonstration products in Medicaid that get them out of FMAP and allow those Medicaid members to buy through their local state-based exchange. Governors are tired of waiting for the federal government to come up with a complete solution. They're starting to take their own action. We've actually made regulatory changes in those markets for ICHRA to make that happen. The average American changes jobs 13 times. The other thing that's going to happen, and people are going to be moving to the right on this spectrum.
AI is going to displace the workforce or cause people to be more gig workers or more part-time workers. There isn't a simple solution for those people today. We need to find a way to do that, and ultimately, the 1,000 plus employer market will come along. The two complaints they always have is, how do I know my employees will pick the right plan? Secondly, how do they get the right network? What I told them is because all of our competitors are on the Lucie Health Marketplace, when an employee goes to define contribution, they can buy any one of the networks from any one of our competitors. Those networks are generally narrow networks, so we have the best PPO in the country at narrow network rates. That's a fundamental difference than where we were before as just the ACA.
But we will talk a bit more about that in a minute. The ACA has improved access in a meaningful way. 73% of individuals in the ACA rate their experience as positive. Can not say that for the rest of commercial insurance. The foundation of a more modern, consumer-driven healthcare system is the ACA marketplace. Not everything about the ACA works, but I believe the network model and the way we underwrite the network to price versus underwriting the members, because we can underwrite them, and the risk adjustment mechanism that we use to level out the risk across all carriers at the end of the year, creates a very solid and stable market over the long run. When you get to 200 million, 250 million, 350 million Americans, morbidity changes do not impact the model. It becomes a very stable marketplace.
The ACA today, here are the people that are in it today. 27% of U.S. farmers and ranchers rely on the ACA. 17% of gig workers rely on the ACA. 48% of enrollees are from small business owners, entrepreneurs, or their employees, where the small business has just given up on insurance and their employees have gone into the market to get products through the ACA. It is the backbone of the U.S. workforce, and by the way, these populations represent more than 50% of the GDP of the United States. They have the weakest support system in the United States. It is essential to the U.S. economy. We have taken almost to half the uninsured in America since 2014. We are instrumental in reducing economic burden. $245 billion worth of uncompensated care has been avoided from 2014- 2025.
We continue to address national issues of 28 million Americans are still uninsured, still have not found their way. Being in the hospitality business that I am in now, I can see it because the employees that we serve that work as waiters in our restaurant, they do not know how to get the ACA. They did not know they could get it. The part-time employees at Hy-Vee supermarkets, 34,000 of them, more than 80% could get subsidies, but they did not know it. The whole idea of helping people understand how to access the system with products that matter to them is going to get at that 28 million uninsured. It is the fastest-growing market of any other segment in America, 9%, and we expect that to continue. It has more choice than any other market in America.
If you work for a large employer, which a lot of you do, two, three plans. It has greater competition. More and more people have entered the market, and while some of the big carriers have left the market, in large part because they can not manage their networks effectively to get to narrow network model, it has created great price stability in employer premium in 2020 through 2025. Here is our first projection, 2029, 23 million lives in the ACA. 2 million will come out through program integrity. We are in the middle of that process now, as a lot of you have heard, with CMS, in spite of what is going on in the legislative side, through regulations, started to get at some of the concerns they have. We still believe that 36 million Americans will grow into the marketplace. 3.4 million new members entered the ACA in 2026.
Choice adoption is increasing it to 22.5 million in 2029. 200,000 new independent and freelance workers enter the market every year. 900,000 new individuals in the ACA due to unemployment each year. There is a basic underlying growth that occurs in this marketplace. We are calling for six million growth over the next three years for a total of 23 million lives in the ACA in 2029. But how do we lead the ACA market. We have a seasoned leadership team. We have a culture of product and network innovation. I will give you an example. In 2025, we bought a product out of Connecticut, a company that had three assets. It had an EDE, it had an agency, a brokerage agency, and it had the second-largest lead generator in health insurance, healthinsurance.org. We bought that company for a relatively small amount of money.
It was even within my authority as the CEO of the company. The result was when we bought that, people said, "Well, what are you buying that for?" Some of our board members had the same question, "Well, why do you need that?" That EDE has become the rail for ICHRA for the whole industry. We created an EDE called ICHRAx. All of our competitors are on it. The fees are cost plus, unlike the $4 they are paying to other EDEs in the marketplace. It does both ACA and ICHRA. But more importantly, because they are all on the exchange, all on our ICHRAx, when an employee converts from defined benefit to defined contribution, they can pick any one of those networks as their product. It does not have to be Oscar.
This EDE became the genesis for Lucie. We believe, and what we did back in 2025, is while everybody believed that somehow the federal government would come to a conclusion that they ought to extend enhanced subsidies, we created a plan where we knew they were not. We advocated, but we did not see the highway to get it done. What we created for the brokers was a vault that allowed them to take their members. We gave them all of their members that were affected by the enhanced subsidy going away, and product alternatives for them to move those members into, and the ability to make that action before open enrollment. Because brokers work on one simple principle: I want the highest level of earnings associated with a joule of energy.
We did the work for them, and when others did not, they went to those other carriers and moved those members to us. That was the secret of our growth. Because while they had all their other members ready by November 1st, pushed the button, they all loaded into the system, our line of growth went straight up. They were out taking other carriers' business and moving it over to us. That was that EDE. That is why it mattered. That same EDE today is working on program integrity efforts and DMI efforts for those same brokers with tools to be able to do that. Again, building capabilities ahead of meeting expectations of unmet needs in the marketplace.
We believe we have a clear path to achieving 18% national market share by 2029 with Oscar, and better positioned to lead a market than our peers with differentiated set of capabilities and a single focus on the ACA, just in the ACA. Janet will talk a lot about that when she gets up. The most important part is that we believe these tools set the stage for ICHRA and build a platform for ICHRA to be able to make that market a seamless move. By the way, a few weeks ago, Mohamed Az got on stage and talked about the new Choice plan that the administration wanted to develop.
We have been working with them for a long time on that, including the idea of having a separate wallet that has KYC capabilities that ensures eligibility instead of CMS having to build their own program integrity efforts. We're committed to building new experiences in the healthcare consumer. This is another part. Our NPS score is now 71 today in an industry that averages zero. We are launching products every day about multicultural needs, clinical needs, and lifestyle needs. You can see sort of the TAM, in 2026 associated with the number of members who think of these kind of products. By the way, in these products, we have as high as an 89 NPS. Our retention is higher than the industry average. We have a less of a hole to fill every year when we're managing our growth.
Reshaping the traditional insurance experiences requires delivering better experiences with less administrative burden, faster payment, and more issues resolved on first pass. We're doing a lot of programs around eliminating provider and member friction, and it doesn't have to be perfect when we launch it. We're talking about the progressive elimination of failure. If we can impact more and more populations as we go in implementing our new tools, we're advantaging our customers every day instead of waiting for a big bang. We don't have announcement deadlines. We're implementing, and again, Mario will talk about this, we're implementing AI every day. It's not a different department inside of Oscar.
It's part of teams inside of our technology and business groups where we have a business person, a technologist, we have a product management person, and somebody who understands AI, all working on improving each of our systems, which are owned by the owner of that business or of that process. We're looking at reducing lag time from service to payment on 100% of office visits and lab tests. We don't do that today, but the industry does it today for pharmacy. Why can't we do the same? Deliver superior experience with 24/7 AI member support for 90% plus of member issues on first pass. Where we do have tools implemented that we're testing, we're seeing as high as 82% first pass resolution from members. There's a lot of hope in the kind of things we're developing for the platform.
That has been driving down our administrative costs. That has created the kind of SG&A ratio that was only an idea in 2027, but we have exceeded it already. I talked a bit about AI. We have very fast AI value adoption. We have unified real-time data sets, modular scalable architecture. We have an AI-driven automation process. The way we ideate, test, implement is very important to the organization and how we roll this out. We've seen a 33% improvement in operating leverage from 2024- 2026, and we've already seen $3-plus billion in total medical cost savings in the same time period. We are applying AI against medical costs, and we have a team that meets almost every day.
We report on it every month on the scores that we put out for our team to be able to get the numbers below the trend that we put into our pricing. Expanding the individual market, unlocking the potential of the individual market, the tools that we built to make healthcare more important for all Americans. That's part-time workers, gig workers, 1,000 less employees, 1,000-plus employees, and other government programs. I think Medicaid will happen before Medicare, but that's the next chapter of the ACA from our perspective, and it's part of what the administration offered back a few weeks ago called Choice. I'll start using Choice from here on out because ICHRA is a terrible name. Here are the number of opportunities that we see in 2026. Half a million lives in Choice. We think it's 2.5 million lives by 2029.
Small, mid-size employers are leading that Choice growth market, but we see large employers also adopting it. Sort of a barbell. This is the opportunity. We think there is a tipping point here somewhere. We don't know where it is. But when it happens, we're ready. It's the way we think about it. We can't tell you exactly when. We haven't put a lot in the numbers other than these. From our point of view, when the tipping point happens, we're ready to handle the volume. We have the capital to do the work. Employers need innovation solutions for the changing workforce. 73 million Americans identify as gig or independent workers. They change their job on average 13 times. That may represent some of you in the room, maybe not. And employers don't want to manage their own healthcare risk.
62% of large employers are exploring active or actively planning to shift to Choice. 91% of Choice adopters say it was the right move for their company. Now they're early adopters. Here's how we think about the network. And I talked a little bit earlier about the network being the largest PPO. 73% of active physicians participate in an ACA marketplace plan network. 57% of local PCPs are included in the average single employer network. The difference is huge. It's a big opportunity. And there's greater purchasing power for the employee. And this is a little complicated math, so I'll try and describe it for you. Currently, today, an employee pays 15% of their premium, and they pay all their out-of-pocket costs out of their own pocket.
With a transition to defined contribution, the employee actually gets up to 26% savings of the employer amount they're given because they get to pick their plan. They get a narrow network, and narrow networks are cheaper than the networks employers offer. That 26% can then be used to actually pay out-of-pocket costs instead of having to borrow for it. It's a net gain for the employer in a number of ways. These are some representative numbers, but it's a huge difference and it's a difficult thing to explain, but the wallet for employees get better when they have a defined contribution plan. We have united our competition around a shared industry technology structure. We built that together. They're paying cost plus, which is less than $1 per member per month versus $4 for other platforms they could use.
They get that as part of their joining our group. They also then get the opportunity to lean into Lucie where we have over 70 other carriers available for them to partner with, and I'll show you a list of those in a moment. Scaling Lucie's leading marketplace platform for carriers, brokers, employers, and consumers unlocks this consumer power to be able to use curated pricing to make better decisions about what they buy and have some people like hospitals stop selling things like certain meds or retail meds that could be bought cheaper or DME, durable medical equipment. Unbundling healthcare from funding is the big idea here. I grew up in Detroit. If you went into an auto dealership and said, "I've got $350 a month for a car, what can I buy?" You're going to get cheated. It's the way it works in Detroit.
We love people like that. If you go in and say, "How much does this car cost? These are the kinds of attributes I want. How much is it? I'll tell you how I'm going to finance it later." That gets to a better purchase decision because you now have made a trade-off on value with your own money. Giving consumers a healthcare wallet that does LSA, HSA, HRA, and HSA all on one wallet, maybe even a credit card, something to think about. Wouldn't it be great that I get to decide how I spend that money, and if my situation changes, the people funding my bucket of money changes, not my plan, not my network. The opportunity to keep members for life by letting them keep their network and change their product as they age is the bigger idea.
What is the value of the lifetime value of a member and their ability to keep their network and to change their plan as they grow older? Young immortals, some of you in the room, young families, older families. Empty nesters, and then seniors like me, all of our plan requirements are different. Wouldn't it be great if not only my health insurance, but all the supplements I buy, all the things that I buy to keep myself healthy, the gyms I belong to, the coaches I have, they're all available for me to purchase through a marketplace where I can trade off value? An agnostic marketplace where all of our competitors are working to get the best cost for everybody. We're working with state and national policymakers to establish the right regulations to make this wallet happen, and we think that's an essential component of delivering on choice.
Talk a little bit about reshaping the marketplace. Today, Lucie, a payer-agnostic healthcare platform, is the premier place for brokers, consumers, offering ACA and supplemental plans. We will expand the platform to offer broader health and wellness products to employers and most consumers, and we will have guided experiences through AI that empower consumers to take control of those healthcare decisions. We already have a couple of those, one on pharmacy and one on imaging, where people can shop to find the best solution for them from a convenience and a quality standpoint. Here is the marketplace. It is all of them, 350 million Americans. Even people on Medicare and Medicaid can have access to this marketplace. Today, on the platform today, we have 70-plus carriers. You can see some of the names there. We have a broad supplemental product ecosystem. These are just a few.
There are others on there, Aflac, Allstate, Cigna, Pivot Health. We have consumer shopping and decision support. Those all exist in the marketplace today. Where we are going is to frictionless setup for consumers and brokers because we believe that brokers are the important second step for employees after their employer moves to defined contribution. Helping with using benefit selection tools to get employees into the right plan does three things. For the employee, it allows me to get extra cash to pay my out-of-pocket costs or extra cash to buy other products or services. For the employer, it stabilizes the defined contribution over time when people are in the right risk profile. So we will have personal AI guidance for broker support and new health products with broader consumer choice.
You can imagine them, whatever comes along, and we are talking to all sorts of people like, LillyDirect and others who want to get onto the platform and have direct relationship with consumers. We are talking to supermarkets who want to have a section for healthy food and healthy eating. So it is an interesting new way and on this system, everybody pays rents on Lucie. The number one marketplace we have by 2029, we expect 2.6 million ACA and specialty products sold in 2029 and 28,000 active brokers on the platform. It will include retail peptides and GLP-1s, which today is 48% cash pay, lab and diagnostic services, consumer wearables, lifestyle and wellness goods and services. Lucie will turn chaos into choice with clarity and transparent guidance. We have a video here to show you next. I do not click right.
Shopping for healthcare can feel like chaos, but there is a better way. Meet Lucie, your one-stop health marketplace. It gives you simple, personalized AI guidance to help you find your way. Find plans based on your budget, preferences, and history with the providers you already know and trust so you can find the options that fit your life best. Manage pre-tax savings, employer funds, and any out-of-pocket costs with Lucie's healthcare wallet, which lets you track where your healthcare dollars are going. Shop medical coverage, supplemental care, and everyday health needs all in one place with a seamless checkout that makes your costs easy to follow and understand. Because when it comes to your healthcare, you deserve to feel confident. Lucie can help.
One of the pieces in there you missed was you can import your medical history in, will help with this analysis and guided buying. The next slide is a dimensioning slide for you. It is a dimensioning slide because we do not know how quickly these marketplaces take off. We already have 800,000 policies for open enrollment coming through the supplemental carriers already for 2027. We are not sure how quickly it will happen. In the ACA supplemental enrollments, there is $30 billion in revenue opportunity. That is the total available market. In choice enablement services, moving employers from defined benefit to defined contribution, there is $125 billion of total available market, and that is an important part of the pie that we believe we need to be engaged in and involved in. In consumer health and products, there is $500 billion for a total available market of $650 billion.
Over on the right, we dimension for each 100,000 members the total available purse, $60 million for ACA supplements and enrollments, $60 million for choice enablement services, $30 million for consumer health products per 100,000 members, and the margins of 35% on the first two and 80% on consumer health products. That is the economic opportunity. The question is, when does it tip? How fast does it move? The reason we made these investments in this marketplace is we believe this will actually be the more dominant part of our capital structure and our market cap in the future. This is where we really make a difference, because when we unleash Americans on healthcare with curated pricing and information like you have just seen, which is available, we can then turn around and we can reshape the cost of the underlying healthcare system and get better costs under control.
We can chase out excess rents. We are building the new consumer health economy. We are scaling the number one consumer preferred individual market. We are today. We are unlocking a larger individual marketplace by looking at Choice and Lucie. We are creating the leading health marketplace for consumers, brokers, and employers for the industry. We believe that by 2029, we will continue to deliver on our 20% plus revenue CAGR, a 5%-7% operating margin, depending on how we invest in capital and price our products, and a $4 plus minimum EPS by 2029. With that, the man with the numbers. I will turn it over to Scott.
Please welcome Scott Blackley, Chief Financial Officer, to the stage.
Good morning, everyone. I am Scott Blackley. I am Oscar's CFO. It is a pleasure to get the opportunity to stand up here before you today and talk about some of the great results that this company has generated, both over the past, and more importantly, what we expect to be able to deliver going forward. This is one of my favorite slides. Whenever I am having a bad day, I pull this thing out and take a look at it, because this is really the evidence of what this team has been able to deliver. Revenue increased 7 times over this horizon since our IPO. During that period of significant growth, our medical loss ratio has just been dropping. We have done that through disciplined pricing and through affordability tactics, and in being able to do that, we have been able to offset trend and drive margin.
Lots of people told us that you would not be able to grow a business in healthcare and have dropping MLRs. I think these slides conclusively prove that we have been able to do both. We have always believed that our technology would allow us to drive efficiency as we scale the business. AI is further powering that opportunity. We will show you the clear evidence of that. Our SG&A expense trends have been cut in half over this time horizon. Really a breathtaking amount of improvement in that ratio over this short time horizon. We are incredibly proud of these results, and we think they position us well for what is ahead. All the trends that I just talked about are culminating in a strong 2026 performance, where many of the KPIs that we are achieving are actually approaching or beating what we had expected to be doing in 2027.
Today, as Mark talked about, we are improving our 2026 outlook by $100 million to a range of $600 million-$800 million of operating earnings, which is double our original guidance. With eight months of experience under our belt, strong underlying utilization trends, we are also improving our full year MLR guidance by 80, or excuse me, 50 basis points to 81%-82%, and the remaining guidance that we have for the year remains unchanged. Let me give you some color on the trends that we have observed through August. First off, overall utilization through August is favorable to our plan. Secondly, on MLR, seasonality this year is tracking according to our plan. We anticipated a more pronounced step-up in MLR from Q1 to Q2. We saw that. That was driven by the mix of new members and lower SEP than what we experienced in prior years.
Third, we have been closely tracking the progression of member cost shares, given the change in our mix year over year. Importantly, what we are seeing on that metric is that members who are reaching their maximum out-of-pocket costs are in line with our expectations. From here, we typically see a very consistent progression through the end of the year. Given where we are at at this point, we feel like we have got good visibility that will continue to move in line with our expectations. Then finally, I wanted to give you an update on what is going on around market morbidity and specifically the CMS One Million Member program. CMS has completed their industry-wide review of 1 million members in the ACA. We received our member termination list, and we have processed that from that program.
All of what we saw through that termination process was consistent with our expectations, and we have processed all of those terminations. That will be reflected in our third quarter results. We do expect that there is going to be a second smaller CMS program later this year. We think that will cover something in the range of approximately 500,000 ACA lives across the entire marketplace. These CMS reviews are really focused on eligibility, making sure that they are removing unauthorized enrollments based on things like missing Social Security numbers or other data matching issues. I just want to make it clear that we have fully reflected the impact of these programs in the guidance that I just walked you through, and we feel like we have got good visibility into the remaining performance through the end of the year.
As we look to next year, we are positioned to increase our market share and drive top-line growth. Our performance to date in 2026 sets a strong baseline for revenue growth and for margin growth. We are encouraged by the rational pricing environment that we are seeing in 2027. Our low teens rate increases are largely in line with national averages and should position us well to take and exceed on gaining market share. Turning to the market, what are we expecting for the market in 2027? We are projecting the overall ACA market in 2027 will be very stable. Specifically, we expect by the end of 2026 that the market will end up at around 17 million lives in the total ACA, and then we expect that the market will stay at around those levels through the end of 2027.
Going back and talking about a little bit of the successes that we have had, and last time I stood up here, we talked about targets for 2027. I am here to give you an update of how we are doing against those targets. I told you last time that our 2027 targets were ambitious but achievable, and I am very pleased to say that our strong performance to date and our current view of next year suggests that we are on track to broadly exceed those targets. Specifically, we anticipate that our revenue CAGR will be between 24% and 27%, will exceed 20%. We now expect that our 2027 operating margin will be greater than 5% next year, and we expect that our 2027 EPS will be greater than $2.25 a share.
Just as you are doing your models in math, we expect that our 2027 effective tax rate will continue to be in the mid-single digits. All of this is being driven by our differentiated strategy and our market focus, and that is cumulatively producing these strong results. I look forward to giving you specific guidance on 2027 at our investor call next February. All right, let us talk about what 2029 is going to look like. As we look out over the next three years, we believe our earnings will be materially higher than where they are today. First, we are targeting revenue CAGR of more than 20% through 2029, driven by a growing individual market, expanding our footprint, and increasing our market share. We expect that revenue growth, as well as an improved MLR and SG&A ratio, will help us to achieve a 5%-7% operating margin by 2029.
Finally, we see a clear path to achieving EPS of greater than $4 per share by 2029. This assumes that by 2029, we will have a tax rate that is, at that time, in the mid-20s, and that our diluted share count will grow at around 2%-3% per year from today's levels. Let me go through an outline a little bit of how we're going to achieve these targets in more detail. I'm going to start with revenue. With revenue, we're obviously keenly focused on growing the top line by more than 20%. We certainly worship at the house of scale and know that the larger we are, the more we can leverage our AI and technology innovations to drive efficiency in our business.
Underlying our revenue assumptions is an assumption that the ACA market grows from 17 million lives at the end of 2026 to something around 23 million lives by the end of 2029. During that time, we'll be expanding our market share and increasing our footprint in our existing regions, and those are our largest growth opportunities. We estimate that those growth opportunities will drive between 17% and 19% growth per year. On average, today, we have a 30% in-market share in these regions, and so there's plenty of opportunity for us to continue to increase in our footprint. We also have a large expansion opportunity in front of us in terms of both entering into new counties as well as entering into new states.
We typically enter into new markets with a 5%-7% market share, and then we grow from there, which translates to around 2%-4% revenue growth through 2029. Finally, we anticipate that new Choice in marketplace products will create revenue growth vectors that can compound over time. While we've not specifically called out this in this waterfall, I'll note that cash and investments now generate a significant investment income that's included in our overall revenue. We expect that that NII will continue to increase through 2029 at a rate of around 10%-15% per year. Let me turn to margin. We've made really meaningful progress on our path to achieving our 5% margin target for 2027. From today's level, we have a clear path of getting to up to 7% operating margin by 2029.
We will continue to maintain our disciplined approach to pricing, and we're going to price to cover rising cost trends. We believe that the inflationary environment that we're currently in is going to remain over the next several years, and so that 5%-7% trend is higher than what we've seen historically of in the 3%-5% range. We think that that will continue over the forecast period. While pricing will play a part in driving margin, medical cost management programs will be a key to driving and increasing our margins. A big part of what drives our margin improvement is the continuing leverage and scale from efficiencies in our tech platform and from AI-enabled process improvements. For example, AI has helped us to automate reviews of things like prior auths. It's improved our claims processing time, and it's increased the accuracy of our risk adjustment submissions.
All of these things are collectively small parts of the business, but when we aggregate them and track them and make sure that we deliver on the commitments, what we are able to do is to offset trend and drive margin year in, year out. I will go through the next few slides with a few more details on these topics. As you saw in my first slide, we have made significant improvements in our MLR over the past several years, and we are beginning to approach our target of 80%. The key levers to improving our MLR include disciplined pricing, you will hear that from us over and over again, but also through medical cost management and doing things like perfecting our network performance, improving the core operations, and creating clinical innovations. Technology obviously plays an incredibly important role in that process.
You will hear from both Janet and Mario some further examples of how AI is today reshaping the cost curve for us, particularly in areas like claims automation and fraud, waste, and abuse. The benefit of all these efforts is that as we see rising cost trends, if we can drive down costs through these affordability initiatives, we can really pass that on to our members and make sure that the product that we are selling is affordable for them, too. We have made significant progress on SG&A. We are not done there. I think we have got a long ways yet to go. Many of the factors that have driven our historical success will continue to do so in the future. First, we have seen significant operating leverage that compounds as we scale. In fact, our fixed cost base has gone from 30% back in 2024 to around 25% this year.
Our technology and AI have already enabled savings in our cost structure that has been allowing us to drive down variable costs, improve our operational workflows, and we expect that this trend is going to continue. I would just note that a lot of these enhancements and improvements are serving us well by driving down costs, but we are also being able to create better member experiences. This is not just an effort to remove costs out of our system. It is an effort to improve the experience for our members and realize value for ourselves as well. Let me pull up on Lucie. Mark talked a lot about the opportunity that is in front of us. The first thing I want to point out is that our greater than $4 of EPS in 2029, that target assumes a modest contribution from Lucie.
We are not relying on that new business to hit our targets. Secondly, the economic opportunity that we see for Lucie is very significant. Right now, today, Lucie is allowing us to capture new fee-based value pools, 70 or so carriers that are currently able to sell ACA and supplemental products through the Lucie marketplace. As Mark talked about, if we are able to capture 100% of the potential value across Lucie's platforms for every 100,000 people that transact in each of these three buckets, in total, that is a $150 million revenue opportunity per 100,000 members. That is the size of the prize that we are working against. Now, we do not expect that we are going to get 100% of all of the fees that are running through this entire marketplace.
But the magnitude of that spend is so significant that if we're successful in getting a portion of that, we think this could be a significant business for us and one that's very meaningful to our results. I just mentioned that this business has several desirable financial traits. Number one, it's a service business, so it's very capital efficient. Number two, it has at-scale margins that are five to six times greater than our core insurance business. Then lastly, this is a technology business, so we think that we can power it with AI and that we'll be able to scale it very efficiently. Let me turn to the balance sheet and our cash profile. Today, we're certainly operating from a place of strength.
We've got $460 million of parent cash and more than $10 billion of cash investments in total as of the end of the second quarter. Our insurance companies are well-capitalized. We've got almost $1 billion of excess capital at this time. The plan that we've outlined today is expected to generate significant amounts of capital in the range of $4 billion-$4.5 billion across the parent and our insurance subsidiaries. What are we going to do with all of that capital? Our capital priorities start with organic growth, reinvesting in the business. These are the highest returns that we can generate on the capital investments that we can make. We'll also continue to optimize our quota share reinsurance programs. These programs are a cost-effective way for us to manage our entity-level capital requirements. We expect to continue to use them.
We'd also expect that over time, we will use them to a lesser extent. We would anticipate that around 60% of our capital generation will stay within our insurance companies, 40% we would seek to have that sent to the parent as dividends, and that capital that comes up to the parent would allow us to do things like pursue opportunistic M&A and manage share dilution. I'll leave you with a few takeaways. Number one, we have already demonstrated that this company has durable earnings power and that we can grow revenue by more than 20% a year. Number two, we're well on the way to realizing that 5% target margin that we set for 2027, up to 7% by 2029, and generating $2.25 of EPS or greater next year, and that we have an achievable path to getting to $4 of EPS by 2029 or greater.
Overall, this plan is going to generate strong cash flows. We think that we have plenty of opportunities to put that capital generation to work to improve shareholder returns and improve the future performance of this company. The targets that I just described to you are based on the business really as it stands today. We can see significant incremental opportunity beyond the scope of these targets if this Lucie Health Marketplace picks up and gains speed over time. With that, I think we're prepared to take a 15-minute break, at which point we'll welcome you back to the meeting. Thank you.
We'll now take a short break. Please be back in your seats by 10:25. Ladies and gentlemen, please take your seats. Our program is about to resume in five minutes. Ladies and gentlemen, please take your seats. Our program is about to begin. Please welcome Janet Liang, President of Oscar Insurance to the stage.
Okay. Welcome back, everyone. Mark started off this morning, kicking us off talking about Oscar's vision for the consumer marketplace and how it's a model for our country's health insurance system. Scott followed up with our strong financial performance and positive outlook going forward. I'm really excited to share with you the expertise and the execution model that is led by our teams at Oscar to deliver the results that you see today. I'm Janet Liang, President for Oscar Insurance. The ACA is the fastest growing segment in the healthcare system in our country, and we are singularly focused on leading and growing in the consumer marketplace. Oscar has significant runway to expand our reach and set the pace for innovation in three really important distinct areas: products, network, and technology.
These three assets are specifically designed for a marketplace where individuals can choose the plan that they want to belong to. I'm going to start back at our Investor Day in 2024, where we have, and I can show you that we have delivered on the commitments that we made to you two years ago. We have a track record of profitable growth that reflects superior disciplined execution. We have nearly doubled our membership, we have doubled our in-market share, and doubled revenue in two years. This is all in a context, I want to take you back. It's in all in a context where there was tremendous uncertainty in the marketplace. We had the expiration of the enhanced premium tax credits. CMS was issuing new guidance for payment integrity and eligibility.
We also saw a rise in market morbidity that everyone became aware of towards the latter half of 2025. The entire industry, all carriers were impacted by this. In a year of great uncertainty, we had a choice to make, and we chose to meet that moment. Let me tell you how we did that. We deeply understand this marketplace. Individuals were losing their subsidies and/or seeing significant increases in their cost share, and they needed options, otherwise they were going to have to drop from health insurance completely. We took a step back and we designed affordable bronze and gold plans that they could move to. Plans that were priced with discipline that generated margin and helped us grow.
The second thing that happened was, because of all this uncertainty, carriers literally exited the marketplace or raised their prices so that they could take a step back because they were not sure what was happening in this marketplace. Instead, we leaned in, right? Brokers at this time were very confused because they had large books of business that they had to move. What we did was we said, "Okay, we are going to reach out to these brokers." Some of them who had never signed an Oscar life before, right? We said, "Look, if you are looking for a stable carrier partner dedicated to the ACA, then that is Oscar." Right? Because of our early outreach and early education, we grew our distribution by 60%. Right? Unheard of 60% growth in our distribution of people who wanted to now sell Oscar Insurance.
This strategy gave us a first-mover advantage during a major market reset, right? Resulting in year-over-year 60% membership growth, 60% revenue growth, and seven points of margin expansion all in one year. Right. Today, we are a stronger organization because of it. We now have the scale to operate with much greater efficiency and have much greater influence in the markets in which we operate. Combined with this pricing discipline, we have shown you that we can expand margin and that we can grow membership at the same time. I am here to tell you, we are going to continue to do that going forward. Okay. We are really, really excited. As we look ahead, we see 65% growth in our addressable market with Oscar reaching national share by 2029 of 18%.
Mark walked you through the tailwinds that will grow the individual market to 23 million lives, right? That is through choice adoption, through a growing gig workforce, and changes with AI driving labor shifts in our economy. But within that, our TAM sits at 9.6 today and is moving to 16 million. This reflects our footprint for Oscar within that national 23 million. So by 2029, we will have a TAM of 16 million. There are three important ways that we are going to get there. Right. Three. Number one, we have an existing footprint, and in that footprint, we are going to mature our market share from 30%- 35%. That is going to add 2 million of addressable lives to our market for us. Second, we are going to expand into an additional number of counties, roughly 400- 600 new counties.
We actually expanded 150 counties last year, so we are going to double that each year in terms of a growth rate and expansion, and that will add three million lives. Then lastly, we are accelerating our choice options and our choice strategy to add another 1.3 million lives in our footprint. I am going to double-click a little bit on choice because choice is a new growth avenue for Oscar and new for some of you in this industry. This year, I just want to share with you that we are already seeing 2x increase in membership from last year. Also this year, we have been busy. We refreshed 250 products for off exchange, where employers and employees can find their choice options.
So, that means that by 2029, we anticipate that we will be at three times the market share in Choice, and our focus is going to be in high-priority markets. We expect to get to 20% share in these high-priority markets. So what's a high-priority market? A high-priority market has three attributes. Economic attributes. The first is that the state has passed favorable legislation in terms of tax credits for employers who are moving to Choice. So tax credits, immediate savings. The second is that there's a very obvious difference between the average premium on the exchange and the average premium an employer may pay. That represents a substantial discount when you move from your current insurance into the marketplace. So there's an attractive savings for employers.
And lastly, we look for markets where there is a good mix of employers from small local employers, but also large employers with multi-state footprints that have a diverse workforce, from part-time to hourly workers, to full-time exempt office workers. When you have that sort of mix in your population, you can quickly take advantage of Choice to take a slice or category of your employee base and move them into Choice without having to move your whole group to give you some early experience. There's early adopters willing to try with certain groups of their employee workforce. So together, this offers us an opportunity of a new TAM in our future. Choice is growing today. I know we talk about it as a future opportunity, but it is growing today.
As we talk to our employer consultants, we talk to the chambers, we're meeting with HR employee councils. We are hearing that over 62% of large employers today are already exploring a shift. Our quotes for Choice options has doubled from last year. There is more quoting activity and more employers interested now that they're becoming aware of the real benefits to move for both their employees and employers. Our value prop delivers the Choice that they expect with significantly more products at affordable fixed prices for themselves and for their employees. So I just went over two things. One, our execution generates profitability, and second, we are growing our TAM. In market, expanding, and through Choice.
Now, let's talk about three really important assets that we have that are unique at Oscar, and I believe that these three assets put us on track to become the number one consumer-preferred individual market carrier. And those three assets, and you hear them from a lot of carriers, but you're going to hear why it's different at Oscar. That's our networks, our products, and our technology. Very different approach when you're designing for individuals and a consumer marketplace. So let's start with our networks. We were fortunate that Oscar was forming at the time the ACA was forming. So we had the opportunity to build our networks from the ground up, understanding the ACA and making sure that we were addressing the needs of the people in the ACA.
Unlike other carrier competitors who had already had very large, wide commercial networks for all their different lines of business, they had to retrofit those networks for ACA. The ACA gives us a very broad supply, with 73% of providers in the country participating in the ACA, offering ample choice for any individual who needs their care needs met. When you overlay choice, this level of choice, with Oscar's advantages, it helps us to cultivate the kinds of partners that we are looking for in terms of providers that are going to work with us for the needs of the individuals in the ACA. Now, together with our partners, our technology, our expertise, our understanding of this consumer segment, we were able to deliver $3 billion in affordability during the last two years. $3 billion in affordability that goes directly to margin expansion and competitive pricing.
When I talk about a high-performing network, this is what you are going to see. You are going to see that we have improved the financial accuracy of our claims payments and timeliness, and we have reduced friction for providers by simplifying prior authorizations and really focusing on anticipating care needs for their patients, our members, and to take the guesswork out of what is going to be covered. That is what you see in a high-performing network that drives affordability. The second thing you are going to see is that we have care teams and care guides and our Oscar Medical Group providing navigation, helping you find the doctors in your network, helping you to get care now. We are there to help you stay healthy and to make sure you are getting to the right care at the right time, in the right setting.
Lastly, what we depend on in terms of driving affordability is going to be our technology and our AI insights, our data platform. We have AI-driven insights that help to prompt, whether it is an automated prompt or whether it is an AI agent prompt, whether it is a human being calling to prompt. We help our members understand your benefits, use your benefits, ways to save money. Also, again, we want to make sure coverage is predictable. We are really focused on how do we integrate the care that you need with the coverage that you get and make that a seamless experience. These high-performing networks, here is what the great news is that these networks have produced this level of affordability, and these networks we built for the ACA, it is the same chassis that is built for our Choice products off exchange. What does that mean?
This means that this design strips 20% of the waste that comes from large generic employer plans, and employers and employees can stop paying for breadth that nobody uses, and can use these dollars to customize benefits and plan options. That leads me to our second asset, our products. Now we have these networks that are core as a foundation for our products that allows us to put money into product design. We customize our products for high growth segments that we want to attract through a new category called lifestyle products, and I am going to walk you through what that means. Many of us are offered We think of products as, I have a PPO, I have a HMO, I have an HSA with my high deductible self-funded plan.
And if you are in the ACA, it looks like I get a bronze, a gold, silver choice, maybe platinum, but not usually. We are here to say that we really understand the individual customer, and I want to tell you that individuals want their plans to resonate with what their needs are at the time in their lives. Our lifestyle products, you can see this, have a net promoter score of 71 versus an industry average of 12. Guess what? People do not really love their health insurance, but I will tell you, they love our lifestyle products. Members save nearly $1,000 on average each year on out-of-pocket costs if they choose one of these plans that is tailored for them versus if they bought a generic plan. I am going to give you three examples of products that do just that.
What we are really good at is zeroing in on what are the health patterns that people experience, what are preferences that different cohorts have, and what are buying behaviors of consumers for each of the cohorts that we serve. Then we build benefit designs, care navigation, and rewards around those distinct needs. We have targeted four high growth segments for our product pipeline. Four high growth segments. Last year, 3.4 million new consumers came into the ACA. When people say the ACA is not growing, not true. 3.4 million new consumers came into the ACA, and many of those new consumers are individuals that fall in one or more of these categories. The ACA is growing with consumers that we want to serve. A great match for us.
What we do is we take this knowledge of how we want to grow, where are segments that make sense for us, and who is coming into the market, and we build solutions around that. I want to talk to you about three of them. You know our Buena Salud, those of you who have been with us, our Spanish-first experience and product, and also our condition-specific products, one of which is diabetes. But three new products for you, just to give you an example of how we have really risen the bar on how we think about consumers and how people buy health insurance. Number one is HelloMeno. HelloMeno is our very first life stage product. This is for women navigating menopause.
We take our core medical benefits, our core medical coverage, and we put on top of that for $0 out of pocket, I am going to say it again, $0 out of pocket, any care that you need that is related to accessing a menopause clinician, hormone replacement therapy, bone density scans, insomnia medications, and anything else that is common and related to the treatment of menopause. Zero out of pocket. We take the barrier of money away so that you can get the care that you need if you are somebody who says, "I have menopause, and that is my primary focus right now." Because of the stigma associated with talking about menopause for women and for their broker distribution channel, we use social media and influencers to reach women directly. Guess what? We saw a 2.5 times increase in direct enrollment versus our traditional plans.
That means unaided by a broker. The good news is we understood there was an unmet need, and we met that need, and we were rewarded by it. Win-win for everyone. The second product I want to talk about is Hy-Vee Health. This is an example of our signature Choice product designed for the employee marketplace. Hy-Vee Groceries, if you don't know who they are, they are a very large regional grocery leader in the Midwest with over 40,000 employees and over 500 stores. They happen to have a very strong health division where they own their own primary care clinics, they have pharmacies, they have dieticians, and a lot of different clinical services for their customers. We partnered with them and we worked with them so that we created a medical product where essentially 90% of the care that you need, which is primary care.
90% of the care needs that you have, if you use their concierge primary care facility, it's 100% zero out-of-pocket. Again, seeing your doctor, basic labs, basic prescriptions. Anytime, unlimited access to your primary care office, zero out of pocket. This combined with what they're really good at, which is discounts and groceries, access to their Food Is Medicine programs, as well as they have local dieticians, so they're all available to the members in this product. Great example of a partnership that expands our reach and also a great brand for Oscar. The last product that I want to share with you is super exciting, and this is our focus on creating, again, affordability and options for people that are buying healthcare, or the healthcare consumer. You'll see this product, it's filed, and it's ready to go for sale in 2027.
We have partnered with Allstate Insurance to create these new bundled products or product bundles. It takes Oscar medical insurance plans combined with Allstate's supplemental cash benefit plans, and together they really help individuals mix and match how they want to take their risk on their cost shares and their deductibles. So greater flexibility, greater coverage, depending on how you know you're going to utilize healthcare. This new partnership gives Oscar access to their distribution network of 38,000 brokers who have not Some have heard about 20% overlap with our distribution, so about 30,000 new brokers who have not written Oscar medical plans previously. This is a big win for us in terms of both offering affordability to our members in the marketplace, but also to expand our distribution reach.
All of this is not possible without technology, the third asset that I talked about earlier. Technology, it's in our DNA, it's in our founding DNA. It's who we are. Oscar was formed because we believe that technology and an integrated tech stack could reduce friction and the hassles in the American health insurance system. We are doing just that. It makes sense that we're an early adopter of AI, because we are a technology organization. At Oscar, technology really underpins every business transaction. It drives our intelligence platform. Now with generative AI, we're enabling automated solutions and workflow at scale. We are essentially operationalizing AI. I want to give you an example. We have, and we're building a very dynamic member profile.
And because we have our own tech stack, we have all of the information real-time from providers on all the activities that they're driving for a member, all the utilization. We also have our 24/7 AI agent, Oswell, where members are querying from symptoms to coverage for how to find help and resources. We have all of that information as well. We track your prescriptions, we know what benefits you've used, we know the plan you selected, so we know what you're interested in. And we take all that information. It's a living profile that's updated instantly. And that profile and that data helps us to develop prompts. Prompts for you to You should go get care now. We need to help you navigate to a lower cost setting to help you save money.
We're going to help you maximize your benefits because we notice you're not using some of the out-of-pocket zero benefits, like your annual wellness visit. Or if you're a diabetic, your $0 insulin program. And of course, above all else, we want you to stay healthy. So we are hyper-personalizing experience at scale. And in addition to that, we take that feedback and we use that to update and to design our future networks, our products, and our tech capabilities. So I am incredibly bullish on the business value that gets generated with an integrated tech stack and the model that we have at Oscar. And Mario is going to talk about more of that with you shortly, but I want to say from the business side, the way that we work together is unlike anything I've ever seen in my 30-plus year career in health insurance and in care.
It is truly phenomenally an advantage. So together we have, remember what I said, network, product, and tech advantage. So in summary, I just want to share with you that we are on a clear path to deliver profitable growth with 18% national share by 2029. And the three key drivers, we have an addressable market that is growing by 65% to 16 million by 2029. So contrary to what you may hear from other industry analysts, we are growing and the market is growing. Number two, networks. Our networks are on pace to deliver continued affordability gains, and we are going to continue to provide exceptional provider experiences at the same time. And lastly, we are going to win new customers because of our relatable, meaningful products that deliver real value.
Our expertise and commitment to the consumer choice is unmatched in this industry, and we are on the path to become the number one carrier in the ACA by 2029. Thank you. And Mario will now take us through our technology platform.
Please welcome Mario Schlosser, co-founder and advisor to the CEO, to the stage.
Thanks, Janet. Excellent to be here. I am Mario Schlosser, the co-founder of Oscar and advisor to Mark on technology matters and other matters. I was sitting here in the front, had to take a picture of Scott standing in front of his now favorite charts, the improvements of Oscar performance since 2021. It really is astounding to reflect on how far the company's come, how well I think we've done the work of becoming just a top-notch insurance company and healthcare company. That was really the original founding vision for the company. That building a unified technology platform will enable us to deliver higher margins at scale. It's exactly, I think, what we've seen here. Of course, it's a team spirit and team efforts to make that happen. But that is something we have been able to show in the last couple of years here.
Before I even jump into this, I just realized this morning, I've been writing code for almost 40 years at this point, which is a crazy number to say. I have never seen anything like we've seen in the last 10 months now. The way in which agentic coding has entered the bloodstream of companies, or should be entering the bloodstream of companies, is totally insane. One thing I'm going to try to do here is to give you a real visceral idea of how we're using leveraging that at Oscar and how you have to have a very different mentality as a company and a different technology platform as a company to even make use of all this stuff that's happening on the AI sides. Okay, why are we able to make use of what's happening on the AI side? Well, we have one platform. Quite simple.
Claims, service, clinical workflows, member experience. It's all the same codes, the same foundation, the same monorepo. That is a big reason why in the last couple of years, we have often been the first, I believe, to launch certain AI tooling. We're the first to launch what we like to call super agents, benefits chatbots. We're the first to launch Oswell. Janet just mentioned him or her. Actually, don't exactly know how to anthropomorphize. We should figure that one out. Her, let's just call it, which is a clinical chatbots. That just works because we have this foundation we can leverage over and over again. Within Oscar or the health plan, that will continue to lead to more operations efficiency, network efficiency, things like that. Better member experience, better navigation, lots of ways the insurance folks can make use of that.
Outside of Oscar on the Lucie Health Marketplace side, we're going to apply these techniques to better shopping, better comparison of information across the industry, and things like that. This is a bit of a grounding chart I thought I'd throw on here. What does it mean? What do we look at when it comes to the peer group of how we benchmark our technology and AI efforts versus others? The peer group isn't other insurance companies. You might not be surprised to hear that. The peer group really ought to be for all of us, for enterprises nowadays, AI native companies. Companies like the foundation labs, for example, that really at this point say, "My engineers don't write code anymore. It's all agent written," things like that. To really live that kind of AI application, you have to have a different environment. The environment is shown here.
You're going to build codes, and build agents and so on one foundation, really, one repo and things like that. You pop that all inside of expert design guardrails. If you deploy your agents in that way, you can then just watch them work and watch them produce results. You get feedback from real outcomes as quickly as you can, and you feed that then back right into building something better. Here's a very nice example of how we've been applying that theory, in a sense, in practice in the last year or so. When we launched Oswell last year, midway through last year, I think we had the first alpha members in using it, the clinical chatbots. It's a multi-agent architecture, so there's pharmacy agents, there is a medical record summarization agent and so on.
These had to all be laboriously fine-tuned and get the instruction written and things like that, and then tested over and over and over again. That architecture is now at the point where we know so much about what good delivery of experience looks like that we have so-called evals all over the place that let the agents modify their own prompt even. There's almost a living system now that improves on itself as it goes along. Of course, again, within expert design guardrails. Our clinicians are there to watch this, our operators are there to watch this, but that's really what you want.
We went as an industry from agents that are in some workflow a year ago, to agents that can write codes and maybe even themselves, now to increasingly agents that can improve themselves, and we got to ride that ladder, climb that ladder up further and further. If you don't have that foundation, if you don't have that mindset, AI is just going to be another point solution for you. You can hire a bunch of vendors, they will stitch you something together. It's not all that exciting, I think. That's when you're eking out some gains, perhaps, but not much more. If you have this mindset foundation, that's how it becomes a part of how the business operates, really. Yes, this is how we build Oscar really from the very beginning.
We like to call ourselves the full stack health plan on the top right, then a little bit of the health plan down here. You got products, creation, network, billing, claims, care, all in that one platform. That gives you a lot more insights into what's actually happening in the platform. Pretty much, I would probably say every operational metric stream now has some agent looking at it, and I will have a slide later on where you see what that means. We have a pharmacy agent that just watches pharmacy claims and can see spikes that we should be looking at, and with some humans involved as well. Health expertise encoded, I think is the next frontier here, and I will have some videos for you, by the way, later on as well.
One of those videos, if you hold that thought for a second, will be about one of our claims operators, not one of our engineers, one of our claims operators who rewrote the software tool he is using to pay claims, and that's really the promise of AI, I think, agentic coding, that you can have non-software engineers build software very, very quickly. Then four, of course, you have to put that in this closed loop and keep improving things. It now took us a couple of weeks more recently to replace a vendor we used to have that's a so-called itemized bill review for us. So bill comes in as a rule-based, it gets applied, but complex rules. We want to pull that in-house, and really in a couple of weeks, we can do something like this now.
Benefit is, of course, we save some money on the vendor cost, but we also get much more information, more real-time as to which rules fire how, and what does that mean for providers, what we have to manage going forward and things like that. So that's the kind of platform you would want and that we have been investing in from the very, very beginning, and that's what's exciting about the company. A little bit about, again, software developments here with AI. AI is changing the calculus of how you think about tackling which projects. There are all these. I always like to say Oscar was never bottlenecked by ideas. Ideas were always flying around more than we could handle, really. Maybe that was in the early years a little bit the problem as well until we focused on also having good numbers.
But it was always in the execution. You had to actually somehow figure out what to do next, and in agentic coding, one thing you can certainly now do is you can check much more quickly if an idea is a good idea. You can build a prototype more quickly. You can get it out there, get it connected. Almost any tool we now build will have several clickable prototypes that get put together very, very quickly and leads to better design from the very beginning there. On the engineering side alone, and this, by the way, also shows the insane speeds that the world is changing at right now.
At the beginning of the year, only about 16% of the codes that were shipped into production systems was written by AI agents, and now that number is almost up to two-thirds of all the lines of code written by coding agents. That is astounding to me. As I said at the beginning, I do not think I would have thought that we would just sort of hand off this craft we have been honed over decades as humans to AI agents and be better off for it. That gives us also about a 2- 3 times faster time to market. Healthcare is not known, I think, for its time to market, insurers are even less known for time to markets.
So many more of these plan design ideas that Janet had, so many more of these ideas around, the actuaries have around, which we look at how should we trigger the costs here now become possible because this now really works quite well. This is a bit of a service slide, I thought. We always like to in every earnings call, insurers now like to talk about the AI use cases they have going left and right. You have to see through that little bit, and what I always listen to is, do they also talk about things that they tried that did not work out? That is often a good sign as to whether what you say worked actually did work as well.
There are plenty of things that do not work, and so we are going to have to continue to be on that journey of figuring that out and learning that for ourselves. Here are just a couple of examples. Provider data is an old bane of insurance companies, getting that right. Right phone number, right specialty, right provider for the right time. The models are good at, if we have several sources that sort of agree but need some nuance in the interpretation, in giving you that nuance and interpreting that. The models can do quite well, and that is one reason why we have been improving our provider data accuracy in just the last 12 months as well. They are not very good at sparse data and making that up.
There is still a lot in healthcare, which I think is a bit of a metaphor, this is for, where you have to go into a practice, into a hospital, and figure something out in the physical space in the real world. So that is where models still need to get better. Fraud waste and abuse is an area where we benefit a lot from very systematic, very deterministic application of rules. Again, not really what the models are that good at. When we experiment with fraud, waste, and abuse, often we see build a model that is, or build a system that is rules-based, not one that is sort of have the agents try to apply interpretation in the moment in time. The final one, incredibly important as well. Nice example here with Lucie.
We've been experimenting there with how do we best get people the best information, recommendation. When we test this with our brokers, we have so many brokers that love working with Oscar. We use them as sounding boards oftentimes. Then we realize they often like simple, clear search drop-down fields more than a sort of black box AI recommendation, because that makes themselves feel like they can stand behind this. It just really matters for the transitive trust that they then deploy towards the prospective members as well. That is going to keep coming back. How you build AI tools people actually like using enormous crafts, I think we're ahead of the curve there in healthcare, certainly in health insurance. Obviously, those are not failures. Those are really good learnings, as long as you can work them back in into what you do next.
Listen to the user and then scale reliably when it makes sense. Okay, we're at the first video here. One thing I will say ahead of time is this will run fairly fast, fairly quickly. We're going to share these videos out separately. I hope I'm not over-promising here. If not, I'll tweet them out. After the talk, what we have-- Can you pause for one second, actually? All right, I'll start talking anyway. Teddy, one of our guys who's been with Oscar for 12 years, I think at this point, started on the phone, then went to the claims team, runs one of our claims queues. He runs the provider disputes claims queue. Obviously, provider experience matters a ton for Oscar.
He built a tool now for himself, started over a weekend saying, "I have to look at too many different systems here." When I challenge or when I look at disputes and providers, I want to build a new one. What you saw happening here just now is him popping into a coding agent, saying what kind of tool he wants. That agent then goes through and builds all this. This is now the real tool here. We really reenacted this, okay? This is not made up. In that tool, you see the tool pull together all these various documents that go into the resolution of a claims dispute, and nicely put this together here. Again, quite fast. We're going to show it to you afterwards again. Of course, when you build something from the ground up, you can build data visibility right into it.
For free, so to speak, you now get all this dashboard stuff here that tells Teddy about how his queue is now working. Now he pops back into the coding agent. Again, coding agent here, going back and forth saying, "I'd like this different. I'd like that difference." What he's building now here is even more mind-blowing, is an AI within the AI. The coding agent built a tool for Teddy, and now he built himself a bot that looks at all the same data where he can now talk to that bot, or his folks on his own claims queue team can now talk to this bot, and the bot starts interpreting data differently here. Again, an AI agent builds within a larger AI coding agent.
All this stuff is only possible because we have an environment that's production, of course, with our production data, and in the same environment with lots of synthetic data, behaves the same way. Teddy can go against this synthetic environment and test all this as if it was the real world. You can see him nicely go through here, pull together all kinds of different PDFs and different instruction manuals that he would have had to otherwise, or his folks would have to look at manually and curate manually here. We did speed up the coding agent working here. You saw that text come pretty quickly. But that was him reenacting how this works, and this was the real tool that then came out of it.
Now, it took the engineering team another probably two months or so to take that tool that he built over the course of starting on a weekend, then another two weeks or so. So there was a lot of still kind of connecting of the dots and things like that, but that's just enormously much faster than it would've been otherwise. This would've been, I would estimate, a six-month project with 10 engineers or so in the past, and product managers around it and everything else. So enormous speed up in actually building this. On the other hand, this was literally one of the people who's adjudicating these disputes every day doing it. You cannot get any better at getting this expertise from the front lines into tooling than if you have it work in this kind of way.
I think that is the absolute future, both of Oscar and of industry overall, and you got to have that kind of set up to really be able to deliver that. Few more examples. This is now starting in operations. I mentioned before, got all these operational queues we can look at. One of them is pharmacy claims. We just have an agent look at these claims every single day and say, "Is there something here in some configuration that looks strange?" There's an example here that popped up a few weeks ago where in just one thing that looked strange that the investigations team looked at as well, was able to confirm about $28 million or so in drug costs that we probably shouldn't be paying for. So that came directly out of this real-time enumeration here. Prior authorization, great example, of course, as well.
Then hundreds of CPT codes in the Oscar prior auth base where we do completely automated approvals. We don't do automated disapprovals ever. That is always done by human beings. But automated approvals are better for everybody. Provider gets it more quickly, our team is less frustrated. So some of the highest volume CPT codes we have, high 90s on approval right now because the AI can collate medical records and things like that. So quite a bit more in terms of leverage we can get there and earn. This is member experience, and you can look a little bit on the right side there as well. This is a bit of a video of Oswell, and we have another video coming in just a second, so we don't have to parse this through too much here.
Oswell now solves about 30%-40% of all member messages it receives right off the bat. Oswell, very purposefully clinical and non-clinical. AI analyzes 100% of every interaction we have. Last year, turns out that people were calling us about changing PCPs because it was confusing on the ID cards. That stuff you got to realize very quickly. It is small enough where people do not realize. They just look at dashboards, but it is big enough to really matter to folks, so AI can help with this. This change in the role of care guides. What is the role of the human in all of this? Care guides have a different job. Their job becomes more about empathy, about handling very complex judgments, required questions, advocacy matters more, things like that.
We can automate so much routine work when the answer is clear and bring in the right person when the decision requires judgments. Finally, I have one more video for you here as well. On the clinical side, one thing we do quite a bit, so we have a large team of nurses doing it, is we reach out to members proactively about issues they might currently have or might face before they go to a hospital for surgery. When they come out of a hospital and we do not feel like they have a good PCP, they sort of catch them when they come out. It takes a while to do the research on a member for a nurse, about 20 minutes. You have to look at medical records. You have to look at discharge documents, things like that.
That is a great AI application, of course, and on the right side here, you see a tool that is live where the tool just looks at all these documents. You might have seen the footnotes there a second ago, six, seven different PDFs the nurses do not have to read anymore, gets all put together in one place and nicely compiled. This preparation time goes from about 20 minutes or so down to less than five minutes, which gets amplified by the fact that you do not reach every member every time. You really, per member you reach, save so much time in preparation, and the nurse is so much more educated about the member. Just quite a bit of opportunity here in managing our clinical affairs much better as well. Okay, one more video here. Going to roll that in a second.
This is a workflow we are putting together at the moment. This is a mix of things we have already launched and things we are launching. Knee replacements. That is a prior authorization. Oftentimes, insurers do this thing where they approve that little thing, but it is a step in a bigger process. What we are now working on here over the next few months at the moment already, launching in the next few months, is let us take that journey and authorize it all the way out and say, "Okay, you will need that surgical procedure, but you will also need medical equipment, nursing care, outpatient physical therapy," things like that. When we authorize this, in a sense, we earn the right as well to then guide the member to the right place at the right time. You got the physical therapist now. It is all real stuff. We get these pictures.
I don't even know where that is here, but oh, yeah, in Florida, of course. We can route you to these PTs that have capacity much more easily. Along the way, because Oswell is there in a helpful manner, you can ask even clinical questions. Maybe your knee is hurting still three weeks after. We won't shy away from answering these clinical questions because we have the confidence that we know enough about the members and about these conditions and built these agents well enough that they can actually do this reliably. Oswell can pop back into the original care workflow we authorized. It can look at that. It can pull in discharge notes from the various physicians you encountered. This is multimodal, so you can upload pictures of your knee there as well.
Of course, ideally, we are the connector, not just the deliverer of care. So we can get you back in with a physician that shows up in our beta as a really good physician for these kind of issues and for you as a member there. So really quite astonishing to see how much more of an ability I think there will be in the future already as in the current Oscar system for having us orchestrate your care, not putting that burden back on the member. Way too often, members are asked to be the advocates and the managers and the accountants and whatever of their own care. We need to be able to take that away from them, and I think have, and that's a big reason why brokers love us, why Oscar grew and out-retains and outgrows other insurance companies.
Lucie Health Marketplace, so much more to be done here as well. Separate from Oscar, as we talked about before, we don't mingle data. We don't mingle sort of recommendations there. But we do know a bunch about how to make members feel comfortable with, again, with AI and with technology and things like that. We have a team in the company that's building a great tool here. We saw the numbers spike as we started talking here, so it looks like people really need to buy better health insurance. Lucie, the experience we're building towards there is one where you will tell us what your healthcare needs are. We can upload medical records. Interoperability is getting a bit easier now. I think we're at the forefront of that as well.
Get these medical records in, reason over them, compare across the marketplace what works best for you as a member. That does not have to be Oscar very clearly. There's so many other good health plans out there. I love the statistic of 75% of all doctors are in an ACA plan, but 57% are in just one plan. You got all this choice. You just got to pick the right plan for you and your family. That really is an algorithmic problem we ought to be able to solve. Then, of course, bundling this with GLP-1s, bundling this with all kinds of other things is incredibly powerful. What, do we have another video here? Do we?
Close it out.
Okay. All right. Sorry. It's me that show these videos here. Yes, enormous opportunity here still. I think we've just gotten going to have gotten to this point with a platform that is not scattered, that is not vendoring out all kinds of stuff and fragments. It's very powerful. I think we've held onto that. To throw agents in the mix has been powerful already in the past two years. It's really taken off, as you saw from these technology numbers here, just in the last 10 months. That will keep layering on itself. There's growth and margin opportunities. We can do much more member experiences, and retention, things like that. There's medical loss ratio opportunities, clearly in care navigation and actuarial insights, affordability programs, and there's tons of SG&A opportunities as well still. Greater automation, self-service, few money interventions.
Again, it's a team sport to have gotten these kind of results here in the bottom left. But the team is incredibly aligned in how they're able to use technology across the board, and that is, for someone like me, incredibly powerful and fun to see, and I'm looking forward to so much more of this. Now we are at the Q&A. Thank you.
Please welcome Mark, Scott, Janet, and Mario to the stage for Q&A. If you have a question, please raise your hand and we will bring a microphone to you. Please state your name and company before asking your question.
I could probably take a nap on these things, huh?
Yeah, I know.
Ooh. They're kind of sleeping chairs. All right. We are ready for Q&A. Who wants to ask? Here, pop your mic up. You're going to
Hi, Andrew Mok from Barclays. Appreciate all the color this morning. When we consider your comments on stable 2027 industry enrollment alongside your targets on revenue growth and market share this morning, it looks like you're expecting industry ACA growth to accelerate to very high single digits, if not low double digits in 2028 and 2029. One, is that right, and can you break down the components of that industry growth, including how much choice is reflected in that?
Scott?
Yeah. We reflected on the fact that we have seen 3.5-ish million new lives coming into the ACA this year. A lot of those trends that are driving that we expect to continue. Things like more and more people who are working multiple jobs. They used to be in an employer-sponsored plan, now they are working part-time in two jobs. We see more and more evidence that that is continuing. We think AI is going to continue to accelerate that. We think that just a core gig economy, individuals who are not part of a large organization, that is going to continue to grow. We see evidence that that has been a big driver of recent growth, expect that to continue. Immigration, while maybe not as high as it has been in the recent past, will continue to be a driver. We see that as a fundamental.
Choice, we talked about the acceleration that we are seeing in that marketplace. I think as Mark talked about this, that is a market that is kind of doing a little bit of a drip, boom. I think what we are starting to see is the real acceleration up the J curve with Choice, where more and more companies are exploring it, and we are confident that that is going to lead to more and more of those companies joining the market. So I would say we are not going to go through each one of those as to the specific drivers, but those are the cumulative factors that are driving growth in the ACA through 2029.
There are two sorts of phenomena. One is employees getting displaced for the part-time job or whatever, and ultimately going and getting their own ACA plan because there is not any structured way to do it. But one of our anticipated approaches is to create an hour banking system within a wallet, so that if I work for multiple employers, the notion would be the employer puts so much per hour worked into that pool. This is something we used to do back when I was a union organizer back in college, create hour banking opportunities for people to amass the money based on multiple employers and then go buy their policies. So there is not a structured way for people to get it, but we now believe we can build structured ways for people to get coverage that are displaced by the employer-sponsored workforce.
Great, and just to follow up on the Choice, you mentioned that there would be a tipping point at some point, even though unclear when. What are the barriers today, and what do you need to happen to unlock that growth? Thanks.
Janet, you want to cover that one?
Barriers? Well, I think choice, what we have been talking about is to actually address and sort of build the, I would say the highway for employers to come onto the marketplace. When Mark talks about Lucie and what we are doing, it is in fact to address some of the friction for employers, just simplifying administrative connections between the employer's employee list, the ability to do the selection and buying for their individuals, and to ensure that the payment transactions work. There has not been an elegant solution in the industry, and that is what Lucie is about, creating that marketplace and putting together the infrastructure, and also the coalition that we form with ICHRAx in order to agree to standardize some of the connection points and integration so there is interoperability. It has really been understanding choice, I think is the first part, that it is an option for employers.
The second is in how do you make it easy for the employers to make the switch.
There are two major barriers in the thinking of employers and in consultants and brokers. Employers are worried about network access. Will all the people that work here have access to a network? We have solved that with ICHRAx. The second is, will my employees be able to keep a competitive plan that does not have me left with just figuring out what defined contribution is every year and having that as the argument. Again, using the broker community to get people into the right plans based on their current lifestyle needs stabilizes the underlying risk of that population. On the consultant and employer side, broker side, brokers hate the ICHRAs because they lose the commission on the group.
But what we've designed is the wholesale sale, converting the employer, then turning all the employees over to the broker to convert them and getting paid commission by whatever carrier they place them with gives them a lot more opportunity, and giving them the tools to do it easily. The consultant side, I think, is going to be a fight over time. I think it's extraordinarily expensive for consultants to convert an employer. It's up to $80 per employee per month. We think there's a cheaper way to do it. We're investigating the opportunities to do that, but that'll be hand-to-hand combat. And obviously, they're going to advise large employers to stay where they're at until they can figure out how they make money from this.
Mm-hmm. Yeah. The truth is, when inflation becomes a point where it just becomes too great of a burden for employers-
Right
they're going to make the switch. Very similar to the change from pensions to 401(k) plans. It was not easy for employers to decide to give up on pensions for their employees. There was a sense of-
Yep
what they needed to provide and when long-range balance sheet impacts, they said, "We got to make the switch." And it's been successful. It's been healthy. It's spurned a whole industry. Very similar-
Steve
I think very similar path.
Go ahead, Steve.
Yeah, great. Steve Baxter from Wells Fargo. Thanks for the questions and all the information. Just to come back to Lucie and the economics, you gave us that slide that had the helpful framework on the per 100,000 economics and the margins you're thinking on that. I guess, how much of those economics are sort of known today, contracted, versus have to be borne out in the market over time?
I think they're known in their current state, so the commissions that supplemental carriers pay as a result of building, of connecting people together. The parts that we're pricing out as we speak is the rents on the actual marketplace itself, and we're negotiating those carrier by carrier. We're having conversations. How much does Lucie get when we create these connections and allow them to traffic through the site?
I know that the commentary, I think, was a modest contribution to the EPS target, any general framework you want to offer beyond that? I guess how should we think about how you might report this business over the next couple of years so we can keep you honest on all these targets? Thanks.
Yeah. I will start with the end of that question, which is, we do not expect to have significant amounts of Lucie-specific disclosure until it becomes a larger part of the business. As we think about how it contributes to the $4, I would just say this: If that business is not successful, we still believe we are going to be able to deliver more than $4 of EPS in 2029.
Thank you. It is Michael Ha from Baird.
Oh.
Hi. On Choice, as employers move employees from group coverage into Choice, how do those members compare with Oscar's subsidized individual members on morbidity, risk adjustment, and retention, acquisition cost, margins in general? Does employer sponsorship structurally improve the risk pool for individual marketplace, or does it create some adverse selection by carrier?
I think that one of the things that we observe is when we see new people come into the ACA, regardless of where they come from, after a short period of time, we can definitely see that the performance normalizes and looks very consistent and similar. We believe that bringing more lives into the risk pool actually stabilizes the risk pool for the remainder of the population. We do think that if we have the ability to create two opportunities to engage that member, one in Oscar Insurance, where you could be a member of Oscar Insurance, if you happen to have a provider and in a network that is in our footprint, we would love to have you be an Oscar member.
If you move and you go somewhere else and you need a different network and with a different employer, Lucie then can capture that life and retain you. The whole business that we're looking at in trying to tackle this individual market is about extending our relationship with members, both through Oscar Insurance and as well with Lucie. We think that by using both of these two vehicles, we're going to be able to have significant duration and significant lifetime value from those members.
On the ill employee side, if you have a sick employee that moves over as part of it, we have the risk-clearing mechanism in the ACA to amortize that over larger numbers of lives. It's just part of the normal routine.
Yeah.
We wouldn't want groups putting their sick employees in and keeping their healthy employees on a self-funded or partially funded plan.
Got it. Thank you.
Yep.
Mario cited 33% improvement in operational efficiency since 2024. With further efficiency still ahead, how much has that shortened the J curve for your new market cohorts, both in time to break even and mature contribution margins? How do those cohorts launching today compare with those, call it from two to three years ago, and how could Lucie drive further improvement through acquisition costs, retention, and admin leverage?
Well, as I spoke about, the goal here is to extend lifetime value. That obviously gives you more opportunity to incur potentially even higher upfront acquisition costs if you have a longer-term relationship. We don't necessarily believe that that's the outcome where you end up with higher acquisition costs. We think we can have very efficient ways of bringing lives into the Lucie marketplace. Just to pull up on how is AI influencing the business. Hopefully, from the presentation today, you have a sense of the pace of how change is happening at Oscar. When I look at how many more projects we can be doing with the same amount of headcount. Our ability to deliver significantly more throughput in changing our systems and delivering more agents with the same amount of people, that is the efficiency that we're seeing.
You hear others talking about spending billions of dollars to try to increase their AI performance. We're actually spending the same amount of money and getting massively more out of the teams that we already have. I think that's important about the quality of people that we have in this company and our technology organization. So, your question about the J curve, I would just say this. We see an acceleration of profitability on all members, so it gives us more confidence in our ability to enter into new markets to hit the margin targets that we've got for those targets. We see the evidence of that every day that what we're building is working.
One more comment before I turn it over to Kevin to ask his question. The other part of this is AI is not just a cost reduction. AI is retentive in allowing people to get service quickly and get things done. So on the growth curve, we've had a lot of volume and scale growth, and part of that is because of AI and the way we manage customers, onboard customers, and service them. Kevin.
Kevin Fischbeck, BofA. My understanding is that the plans that you offer in the Choice market are basically the plans that you offer on the exchanges. If that's true, do the plans in the Choice market have risk from legislation? Did the pricing go up a lot on the Choice market this year when it went up a lot for the broader market? And if that's the way that it works, how do employers think about that regulatory risk as they think about moving people onto the Choice market?
We are doing both on and off exchange products. We price it out based on what we think the mix will be.
Okay, the off exchange being more stable, you would say?
Yep.
That gives the employer then visibility.
Literally what the employer does is they take what they are spending on healthcare less the employee premium share, and they divide it across their employees, and everybody gets the same amount.
That is pretty much the standard approach.
Kevin, if you look at the performance of the ACA on trend, I think the trend over time in the ACA has been more favorable than what we have seen in the commercial space. Yes, there has been some near-term pressure on rates in the ACA. But we think that with a stabilizing market going forward, we will see a more consistent profile. We think that is going to be better than what we will see in commercial. I don't think that the short term headwinds in pricing that may have happened over the ACA in the last year or so are an impediment for Choice to continue to grow.
Okay. You kind of touched this on answer to a previous question, but I guess, Mario, you said the first part of making AI really successful is having one platform. Can you give some examples about what that means exactly? When you look at something and say, "I couldn't possibly have done XYZ if I was on multiple platforms, or it would take me twice as long, or it would cost X amount." How should we think about what those barriers are that maybe others are hitting that you're not hitting?
Yeah.
Just maybe some way to quantify it. Thanks.
Yeah. I think if you take that Teddy workflow, right, the claims provider disputes queue tool that we built there, that is the kind of thing that in a normal insurance company would probably hit different systems and even different vendors potentially. You have a vendor that might be giving you some data, a provider or whatever, might have another vendor that does a part of the bill review there and stuff like that. In our case, because it's all in one place, Teddy can sit down, say, "Write me this tool that does this all automatically." And the agent will know where to look internally without having to go to other vendors, leave the cloud we're in, things like that. I don't think you could build something like this if you didn't have one unified platform. Oswell is a great example as well.
One of the things we've been doing with Oswell is to give it more and more of a chance to act proactively. So for Oswell to go out and say, "I'm going to send you a message now. I'm going to approve something proactively," things like that. And that means adding more and more endpoints to it where it can act, where it can really invoke our internal systems. Again, if we didn't control these internal systems, if we had to step outside of one system cloud to go into another system's cloud or whatever else, or mainframe even, it'd be very difficult to do. And so the speed of putting this to markets and the ability with which we can rewire, I think is that. Overall, I would say it's always been somewhat difficult to pin down exactly what part of Oscar's performance is technology driven versus not.
I think that's basically impossible to do. But if you look at, this is why I also like Scott's favorite charts. If you look over the last five years, it is so clear that I think we've outperformed pretty much everybody in the ACA or in health insurance, broadly speaking, from how every one of these metrics improved. And that, to me, wouldn't have been possible if you didn't have both competent operations and leadership in there, and then also the technology subset in which this works. And so that'll just keep being the case.
Hi, Sarah Conrad from Goldman Sachs, asking on behalf of Scott Fidel. Can you clarify the MLR guidance dynamics that you provided on slides 45 and 46? On slide 45, you showed your operating margin targets, where you're pricing to anticipated cost trends. So both pricing and cost trend are increasing 5%-7% annually. But then on the next slide, you showed that MLR should increase by 150 basis points through 2029. Can you just clarify the drivers of the 150 basis points of MLR improvement?
I wish that I could remember what was on slide 45, but I'm just going to say that I'm drawing a blank on which one slide 45 exactly was. So I would just maybe answer the question more generically to say we expect continued progression of the MLR from where we are today, through 2029, approaching 80% is our target. We do expect that trend is going to be 5%-7% a year. What we always do going into the year is we have a list of affordability initiatives. Every month, we look at that list. Every month, we set and adjust the targets for the performance of what we anticipate we'll be able to remedy in terms of throughout our system on affordability. And that is how we, even if we just price flat to trend, we think we can create margin.
The example that Mario showed with that pharmacy item, that is a perfect example of something that two years ago, it would have taken a team of actuaries a month and a half of intensive data analysis to find that specific thing. Now our AI agents are finding that in real time. The speed to closing what looks to be a fraud, waste, and abuse issue is happening in weeks versus months. Those are the examples of the kinds of initiatives that we have. We have those that sit in network. We have those that sit in operations. We have those that sit in fraud, waste, and abuse. They are refreshed every month, as I said. It is part of the management process of the company. That is how we claw back on trend and why we expect to get to an 80% MLR by 2029.
I just have a quick question on metal mix trends. Do you expect that the mix shift to bronze is likely to continue in 2027, or are you anticipating a different scenario?
Stable. I can take that. We see it as stable. It is after this big shift that happened, it is essentially going to stabilize at this point going forward. I think that unless there is another big event that is not organic to the ACA, it is kind of reset now.
Jess Tassan from Piper Sandler. Thank you guys for the detail today and for taking the question. One for Scott first. Can you just elaborate on where the 50 basis points of MLR favorability is coming from in the revised 2026 guide?
Yeah, it is really, Jess, I would start with some of the comments that we made at the second quarter call. We have just seen consistent performance in utilization that is favorable to our expectation. At this point in the year, looking at the results through August, we feel very comfortable that we have got the visibility into the full-year performance. So, that extra couple of months since our call really allowed us to say, "Let us go ahead and lean in and bring that favorability into our guidance." I talked about some of the fundamentals here, utilization that is favorable. Member cost share progression, which is fairly linear from this point of the year forward. We have seen that very much right on what we would anticipate.
There is really nothing happening structurally where you would expect a spike in utilization with those members, so we really believe that we will continue to see performance that is consistent with our expectation there. So it is all those fundamentals that is allowing us to improve our MLR guidance by 50 basis points.
Got it. Thank you. Then, maybe for Mark, can you just give us a little more detail about some of the Medicaid demonstrations you were describing? What does the state need to do in order to allow their Medicaid beneficiaries to purchase coverage on the exchanges? What is the timeline there? Then just how do you reconcile benefit differences, Medicaid versus Choice? How is the funding administered? Just any detail on how exactly that gets operationalized. Thank you.
Okay. Well, the very last part is still in process. We are not anywhere near operationalizing it. I met with the National Governors Association, gave a talk on healthcare reform and the development of Lucie Health Marketplace and other things. Governors are like CEOs. They actually have to run an organization. They are in charge of the budget, versus what goes on in Washington. They are frustrated, a lot of them, that Washington has not been able to resolve all the Medicaid issues, particularly the FMAP, the federal exchange. So actually, interestingly enough, a lot of the state-based exchanges have been started in red states because they are just sort of disgusted with the whole process. As we talked about this idea of Choice, they very quickly glommed onto, well, wouldn't that be good for Medicaid as well? So we have a number of conversations going on how that could work.
They obviously would need a demonstration project, relief from the federal government in order to do it, and we are still early in that process.
Jonathan Yong, UBS. Thanks for taking the question. As you think about the near term and medium term here in terms of enrollment, how are you thinking about the competitive dynamics, especially as it seems one of your key peers is a little bit more aggressive in pricing relative to how you are shaking out, particularly in Florida? How do you think about retention as you think about towards 2029?
I can take that.
Yep, go ahead.
I can take that, Mark. We are priced very competitively for 2027. When you look at our footprint, we are essentially at 14% rate increase, and the competitors are on average of 15%. I would say we are very competitively priced, particularly in Florida, where we want to grow. I just want to emphasize again, we discipline pricing. We price for margin, our operating income, and then we price for growth. We have a great track record, and we are really confident in both our growth numbers and our margin for next year.
The other thing I would just say is pricing is such a local thing.
Right.
We are talking about national averages because I think it gives you a sense of on average, we are in a competitive spot. I think that as we look market by market by market, in the markets where we are really looking to grow, when I look at the price there, I feel like we have very competitive pricing. We have very strong distribution programs and plans. The market is competitive. Pricing is competitive. But I think it is rational this year, and based on our position, we feel confident about our ability to grow.
Okay.
By the way, the price differential in and of itself is not enough to move some of our customers.
Okay. As we think about 2029 and getting to the 5%-7% margin, you are talking about 80% MLR below 15 G&A. What do you need to happen to get to that below 15 G&A? Is it more leverage that you are going to pull, or does something else need to happen to get there? Thanks.
Scale, AI.
We will just keep doing it. We have in process AI projects all the time. We do not view it as a different thing done by a different group. The groups that work on each of the platforms consider AI an important tool in helping get the project right.
I am next. Okay, great. I guess I am next. Dave Windley at Jefferies. Thanks for taking the questions. I wanted to first ask, in what percentage of your markets are your lifestyle products? How much growth or expansion in footprint is available there? Are those products, do you target higher margins, or do you more favor passing the savings of the customization to the member and target inline margin?
Can I take that in general? In general, our lifestyle products today represent just under 10% of our total membership. We do not offer every product in every state. So within a state, it is probably a higher share of the membership, depending on which state we are looking at. All of these products are priced for margin, and they perform really well. They are our fastest-growing segment of products that we have.
Greg.
The beauty of that product as well is that it has, because it is so customized to the individual's needs, it can generate a favorable margin for us, but at a lower cost for the member. That is the perfect relationship. It also has extraordinarily high retention. So once we make that connection with that member, we have higher retention in that cohort than we do for an ordinary plan.
Yeah. It is not a loss leader. If we could, we would continue to grow that percentage mix into the lifestyle products.
Sure. Great. Thanks. I wanted to make sure, zooming out on broader market numbers, I wanted to make sure I followed some numbers. You mentioned a couple of times the 3.4 million new members to the exchange market, I believe, is the number that you are referencing. The overall exchange market, I think in total is declining this year from 23 million to, I think you are saying, 17 million by the end of the year, which suggests over nine million in dropouts, in churn, which is remarkable. In that context, you are lowering your MLR targets. So, very interesting. If you could perhaps talk about what you are. I do not think your churn experience is quite what that market number would suggest, but what are you seeing, and are the dropouts basically in line MLR with the stayers? Is there not a significant morbidity shift from that?
Do you think with this massive amount this year that that is basically over? Just understanding what impact that 9 million dropouts has on the profile of the market. Thank you.
Yep. Mark spoke about this. We planned for this event where we would see the change in enhanced subsidies creating a situation where we expected a lot of dropouts. We have seen that. We expected that CMS program integrity efforts would also have the effect of moving some people out of the market. We priced for a market that we expected to contract by 30%, so that was built into our pricing, built into our reserves. We think that the market is actually performed better than that. Overall, I don't think that based on the levers, the performance that we've seen to date tells us that our estimates of what market morbidity was going to look like were pretty much spot on. The fact that we've seen utilization performance against our pricing, all of those things are working well for us.
Yeah. I think maybe just a brief comment on how we build our plans so that people understand them. When we build our plans, we build a three-year strategic plan. We add a third year every year, and when the third year becomes the first year, it is the operational plan. It is all linked together, and every year we reevaluate each of those positions. Our operating plan is never different from our strategic plan. More importantly, when we get to the operational plan, we develop a set of risks and opportunities. What could go great, what could go wrong, and we value those, and we like to make them 50/50 so we know we have a 50/50 plan.
We then create for each risk and opportunity a lever, so that when that risk or opportunity happens, we're not scratching our head going, "What happened and why?" We actually know what lever to pull. In 2025, when everybody had their big happy summer notice from Wakely, and two of our major competitors withdrew guidance and had to figure out what happened. We didn't. We had a plan in two days. 48 hours, we knew what our new numbers were. So we didn't withdraw our guidance. The whole idea is that when you build the plan, it is wrong from the moment you start. But when you have an assessment of all the good and bad that could happen, and you have a plan for each one, and you have a management process that brings the numbers down every month, which is what we do.
We get together for a week, and we go through the whole plan front to back. We know how to operate the business to meet our commitments to all of you. Our commitments are built on all those risks and opportunities.
Thanks.
Hi, Lance Wilkes from Bernstein. A question on the SG&A opportunity, and if you could talk a little bit about maybe within Oscar Insurance, what are the major categories where you feel like you can keep rinse and repeat with AI, keep taking the costs out, and maybe what are some of the categories that are stickier, thinking of like maybe
I'll take one of the examples, and then Mario, maybe you could name a few. The dispute resolution one. When I showed up in 2023, we had, in provider disputes, almost $300 million in backlog. Weren't getting into our reinsurance arrangements, which we had a lot of, and weren't getting into our risk adjustments. Think about all the economic impacts of having AI do it. And figure these things out and know what's right or wrong. It's more than just an operational cost reduction. It's a revenue enhancer. Because now we have the ability to make sure that our risk adjustment's right and that we're getting our fair share when we submit it. We're also getting our reinsurance recoveries, which show up in our numbers.
It's multifactorial when we think about all the economic. It's like tentacles going into the organization, providing good news in a lot of different places. What you're seeing in the SG&A number, as crude as it is and as crude as it's always been, is just a calculation. But I would argue it's not just cost reduction. It's a lot of these tools that make what we do easier, which does result in cost reduction. But I would argue that SG&A number's down as much by scale and growth, which was driven a lot by AI itself. It's hard to dimension it in just a pure calculation lens.
The other thing I would just comment on SG&A. About 10% of our SG&A is structural to the ACA. Think of that as taxes, exchange fees, and distribution. Very hard to change the curve on those things. We are always talking to regulators about the fees and how those fees just are a headwind to affordability. Our opportunity is to basically bring those variable costs that sit above those structural expenses down. I think that at our absolute best day, we will have nickels of costs on top of those structural costs.
Gotcha. Then just a quick question on the vision with respect to Lucie Health Marketplace. Where I was interested there is if you become that marketplace, it would seem that you could be the consumer interface as well, and your product and capability would disintermediate certain components of carrier products and things like that. As you do that, how do you do two things? How do you balance where it is too costly to go further because maybe the amount of integration you have got to do with claim systems of carriers or things like that.
How do you pace the investment you are going to be making as you build out this business?
Well, the last part of the question is the tough one because you have to have buyers and sellers. As you are pacing the changes, you have to have somebody that wants it, right? We have to. That is where the unmet need is met by a capability we build. That is going to be the trade-off. Quite frankly, we are looking at senior people that have built those kinds of markets before to come and help us do that because that is a calculation that even my brain cannot get my head around, it moves as fast as it could move. That is an important. So the team that we put together around this and are putting together around this, critically important.
But I think the way I like to put it is I said to Janet when we were talking about this marketplace nine months ago, 10 months ago. I said to her, "When we get into this space, all of your competitors will have access to the things you will have access to. And how you compete is going to be entirely up to how we view, how we differentiate as an organization as a result." And I think that's fair to everybody that sits around that table. And we may disenfranchise some people, but it's part of the competitive framework. It's not by icing them out.
Great.
One last point on Lucie. We have built a significant amount of cost into the plan to support our aspirations there. So I feel like we've got a balanced plan that has a significant amount of expected spend there. And again, we will be targeting the $4 of EPS, regardless of the performance of Lucie. So, while I think that that business has a huge opportunity to grow, we would only increase spending if we're seeing more opportunity arise there. And again, we would expect to hit the $4 target in 2029, regardless.
One last question. Bueller? I think that's it. That's it? Yeah. Great. So I will stand up here. These chairs are impossible to get out of. All right. So these are some of the awards we've won as an organization in our healthcare innovation journey. They're comforting, but they don't tell the true story. The true story is in our retention and the customers that like what we do for them. And so when you hear in our Buena Salud, our Latin programs, that we have an 89 NPS, it's a big deal. And we think that that's huge on this journey toward having customers for life. So, I think this is good, but it's great when we see it in our customer base and in our growth and the kind of service that we're providing to people.
So just as a reminder, we are the leading new consumer healthcare company in a healthcare economy that we believe is shifting. We have a proven track record. We believe we're accelerating choice. Our engagement with the administration and the talking points you heard over the last few weeks coming out of CMS were in large part due to our government relations people and all the work that we've been doing with them over the past year and a half. We believe Oscar is the individual number 1 market maker in the individual market, and we believe Lucie really has opportunity. We don't have Lucie in the numbers because if we were to put them in there, we'd have scared the hell out of all of you, including us.
What we want to do is we want to have to be a joyful celebration when the tipping point happens, and all of a sudden it starts happening. I think we've seen that in every marketplace that's developed in our economy and the biggest companies in our economy today. I really appreciate the time. We have lunch in the Hamilton Hall, which is over right down the stairs. Please join us for a bite to eat. I want to thank you for your time and attention. Obviously our team is available to all of you for any further questions that you have as a result of your time here. Thank you.