Health Plan Weekly

Underscoring the delicate — and sometimes dissonant — balancing act the company plays, UnitedHealth Group’s fourth-quarter earnings call had two overarching themes: philosophical musings about what’s wrong with American health care, and assurances that medical cost pressures that plagued the firm in 2024 won’t follow it into 2025. Still, the company’s stock dropped on the news that its fourth-quarter medical loss ratio (MLR) was higher than expected. 

The Jan. 16 conference call was UnitedHealth’s first publicly broadcast event since the Dec. 4 death of Brian Thompson, who led the company’s insurance arm and was gunned down outside a New York City hotel where he was slated to participate in UnitedHealth’s annual Investor Day. Luigi Mangione, 26, is now facing charges related to a crime that police have indicated was motivated by simmering anger at the health insurance industry.  

As the worst wildfires in Los Angeles history continue to ravage the area and drive people from their homes, health insurers are stepping in to provide needed care to patients and assistance to employees. 

Insurers have submitted plans to the state for how they will respond to the emergency, including relaxing prescription refill limits and allowing members to seek care at out-of-network facilities for in-network costs. The plans were in response to directions issued by California’s insurance commissioner and the Department of Managed Health Care as the fires continued to displace tens of thousands of people. 

Alignment Healthcare, Inc. and Clover Health Investments Corp. each touted their Medicare Advantage membership growth and financial strength during the J.P. Morgan Healthcare Conference on Jan. 15. They were the only two health insurers to present at the annual conference, which gathers many of the leading health care companies and investors in San Francisco. 

A year ago, CVS Health Corp. and The Cigna Group both participated at the J.P. Morgan conference, while CVS, Centene Corp. and Humana Inc. were among the managed care organizations that presented at the conference in 2023. Cigna, Centene and Oscar Health, Inc. were scheduled to present this year, but they pulled out, STAT reported.  

In the finalized version of the Biden administration’s last regulation governing the Affordable Care Act marketplaces, CMS made few changes from the version proposed in early October. Yet industry experts say it’s still worth flagging a few under-the-radar provisions that could have a lasting impact on how insurers design their plans — even amid a new presidential administration that will likely look to make its own impact on the exchanges. 

In the 2026 Notice of Benefit and Payment Parameters (NBPP), which was finalized on Jan. 13, CMS cemented its proposal to incorporate HIV pre-exposure prophylaxis (PrEP) services into the 2026 risk adjustment models as a new, separate factor. Essentially, CMS had to create a class of predictor variables called affiliated cost factors (ACFs) to apply to PrEP, because it didn’t fit into the two other categories used in determining risk scores: the hierarchical condition category or the prescription drug category.  

Total U.S. health care spending increased by 7.5% to $4.9 trillion in 2023, according to CMS. The growth rate outpaced the 4.6% increase from 2021 to 2022 and the average annual growth rate of the 2010s. As health care spending grew faster than the gross domestic product in 2023, the share of GDP devoted to health care went up to 17.6% in 2023.

On a per capita basis, health care spending went up by 3.1% year-over year in 2023 after adjusting for economywide inflation based on the personal consumption expenditures index, according to an analysis by KFF. Out-of-pocket expenditures also saw an increase, averaging $1,514 per capita, which was mainly driven by growth in out-of-pocket spending for hospital care, physician and clinical services, and nursing care facilities.