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健康保险金融脉搏——2025年夏季版

金融 2025-09-24 奥纬咨询风与林

2024法定财务结果 — 各市场利润率恶化

2024年，全市场税前利润率下降至-0.3%，首次出现负值，主要原因是所有业务线的行业损失率较2023年增加。

2022-2024保费不足准备金（PDR）增长

PDR总额从2022年的22亿美元翻了一番，达到2024年的44亿美元，每年约增长11亿美元。非公共蓝十字公司PDR总额增长最大，翻了三倍；公共公司PDR总额约翻了一番；其他公司增幅最小。

2025年第二季度大型公共公司财务表现挑战持续

2025年第二季度，大型公共公司保险业务的平均利润率比2024年第二季度低0.5%，主要受Elevance和UnitedHealthcare损失率上升的推动。

市场角落 — 适度并购活动和公共公司估值持续下降

2025年上半年，健康计划之间的并购活动有限。在更广泛的医疗保健行业中，支付方和医疗服务提供者继续通过人工智能和关键治疗领域的收购来关注运营改进，这可能在未来导致并购活动增加。总体而言，健康保险公司的市值和股价下降，而标普500指数在2025年第二季度上涨了10%以上，包括UnitedHealthcare Group股价的显著下跌。

市场细分财务表现

商业市场：2024年，商业保费PMPM增长6.3%，达到580美元，公共公司增幅最高（+10.0%），非公共蓝十字公司增幅最低（+5.0%）。全面受保团体市场参保人数同比下降4.5%。2024年报告的综合损失率为88.0%，较2023年上升1.7%。公共公司（+2.1%）和非公共蓝十字公司（+2.2%）的损失率上升幅度最大。
个人市场：2024年，个人保费PMPM总体保持不变，平均为555美元，公共公司（+3.9%）和其他健康保险公司（+2.5%）的保费有所上涨。整体参保人数同比增长27.1%，主要受增强型保费税收抵免和从医疗补助资格重新确定中转移参保人数的推动。2024年报告的综合损失率为85.3%，较2023年上升0.9%。非公共蓝十字公司的损失率上升幅度最大（+3.8%）。
医疗保险优势：2024年，医疗保险优势（MA）市场参保人数持续增长，公共公司（+6.3%）、非公共蓝十字公司（+6.8%）和其他健康保险公司（+8.8%）的增长率相对均衡。2024年报告的综合损失率为89.9%，较2023年上升2.5%，各公司类型增幅相对一致。
医疗补助管理式护理：2024年，受医疗补助资格重新确定的影响，受保医疗补助计划参保人数大幅下降。非公共蓝十字公司降幅最小（10.8%），公共公司（15.6%）和其他健康保险公司（19.4%）降幅最大。2024年报告的综合损失率为91.3%，较2023年上升3.7%。其他健康保险公司（+5.8%）的损失率上升幅度最大。

大型公共公司财务表现

净利润趋势：2025年第二季度，四家大型保险公司的平均净利润率（净收入/保费）为4.2%，较2025年第一季度（5.3%）下降1.1%，较2024年第二季度（4.6%）下降0.5%。UnitedHealthcare的利润率从2025年第一季度的5.8%下降到3.1%，主要受疾病发生率和成本趋势上升的影响。Elevance的利润率从2025年第一季度下降0.9%，主要受ACA和医疗补助业务疾病发生率上升导致医疗成本上升的影响。Aetna CVS Health的利润率从2025年第一季度下降1.5%，主要受团体医疗保险优势业务损失的影响。Cigna是唯一一家利润率上升的公司，从2025年第一季度的7.6%上升到8.2%。
医疗损失率：2025年第二季度，整体未加权平均损失率为87.9%，较2025年第一季度（85.2%）上升2.7%。UnitedHealthcare的损失率上升幅度最大，从84.8%上升到89.4%。
运营费用率：运营费用率（运营费用/保费）从2025年第一季度的7.1%下降到6.1%，继续下降趋势。Cigna、Aetna CVS Health和Elevance均报告了下降，而UnitedHealthcare基本持平。

会籍情况

医疗补助：2025年第二季度，公共公司医疗补助会员人数同比下降1.1%，但医疗补助参保人数仍比疫情开始时高约20%。
商业：2025年第二季度，商业会员人数同比下降约0.3%。

并购活动

2025年上半年，健康计划之间的并购活动有限，没有宣布任何重大交易。在更广泛的医疗保健行业中，支付方和医疗服务提供者继续通过人工智能、制药和关键治疗领域的医疗服务提供者整合来关注运营改进，这可能在未来导致并购活动增加。

市值

2022年第二季度至2025年第二季度，七家跟踪的公共医疗保健公司的市值的综合下降为-33.3%，而同期标普500指数上涨了63.9%。2025年第一季度至2025年第二季度，标普500指数上涨了10.6%，而大多数七家跟踪的公共医疗保健公司经历了市值下降，只有Aetna CVS Health略有增长。UnitedHealthcare的市值下降幅度最大，为40.9%，主要受Q1业绩不及预期、全年指引下调、领导层不确定性以及医疗保险优势业务成本高于预期等因素影响。

Summer 2025 We present the Summer 2025 edition of our Health Insurer Financial Pulse! This edition of Pulse includes thereported annual statutory financial experiencefor health insurers through 2024,Premium DeficiencyReserves (PDR) trends, highlights fromPublic Companies’ Q2 2025 financial statements, and a summaryof recent health planMerger and Acquisition (M&A) activity and valuation trends. Our aim is to keep youabreast of key market trends and dynamics that impact health insurer financial results and profitability. Wehope you enjoy the newsletter and find it informative. Please look for our next edition in Fall of2025. 2024 statutory financials — Individual, Group, Medicare, and Medicaid marketsmargindeterioration The market-wide pre-tax margins decreased in 2024 to (-0.3%) and were negative for the first time in recentmemory with increased industry loss ratios in all lines of business compared to2023. 2022-2024 Premium Deficiency Reserves (PDR)increasesTotal amount held in PDRs more than doubled from 2022 ($2.2 billion) to 2024 ($4.4 billion), with anapproximately equal increase of around $1.1 billion each year. Non-Public Blues had the greatest change,tripling their total PDR amount, while public companies approximately doubled theirs and other companieshad the smallest proportional increase over the period. Q2 2025 large public companies financial performance challengescontinueWe reviewed large public companies’ profitability for their insured business and noted that reported profitmargins for Q2 2025 were 0.5% lower than Q2 2024 on average, with the reduction driven by Elevance andUnitedHealthcare increased loss ratios. Continuing profitability headwinds in 2025 remain achallenge. Market corner — modest M&A Activity and public company valuations continued to decline inthe first half of2025 Limited M&A activity was reported between health plans in the first half of 2025. Within the broader healthcare industry, payers and providers continue focusing on operational improvements through AI and growthof acquisitions in key therapeutical areas, which along with consolidation and vertical intregration could leadto greater activity in the M&A space going forward. Overall, market valuations and stock prices decreasedfor health insurers while the S&P grew over 10% in Q2 2025, including UnitedHealthcare Group which saw awell-publicized decline in its stock price in the secondquarter. IN THIS ISSUE 1 01Full-Year 2024 statutory results by market 122024 PDR trends 13Q2 2025 Large public companies’ financialperformance 14M&A corner and Q1-Q2 2025 market capitalization HEALTH INSURERS FINANCIALS BY MARKET We summarize the profitability trends of carriers with 2019-2024 annual reported statutory financialinformation. We also summarize enrollment and loss ratio trends in the Individual, Group, Medicare, andMedicaid markets. Overall, pre-tax margins decreased in 2024 to1-0.3%, with increased loss ratios in Group,Medicare, and Medicaid compared to2023. ALL MARKETS Commercial, Medicare, Medicaid, and Other Profitmargin All markets pre-tax profitmarginPublic vs. Blues vs.Other Margins in 2024 decreased for Public, Non-Public Blues,and Other Health Carriers. Public companies decreasedfrom 3.2% to 1.5% to2023. Pre-tax profit margin (as % of premium) Non-Public Blues and Other Health Carriers reportednegative margins at (-1.9%) and (-2.6%),respectively. GROUP MARKET Public companiesNon-publicBluesOther health carriersAll health carriers PremiumsPMPM Group premiums PMPM increased in 2024, withaverage market premiums reaching $580 PMPM, anincrease of 6.3% from 2023. The increase is the lowestfor Non-Public Blues (+5.0%) and highest for PublicCompanies (+10.0%). Enrollment2 Public vs. Blue vs.Other Enrollment in the comprehensive fully insured Groupmarket continued to decline in 2024 decreasing by4.5% compared to2023. Lossratio Public vs. Blue vs.Other The 2024 reported loss ratio of 88.0% is an increase of1.7% relative to 2023. All carrier types saw increasesand overall increase was driven by Public Companies(2.1%) and Non-Public Blues (2.2%), while Other HealthCarriers’ increase was limited(0.2%). INDIVIDUAL MARKET Public companiesNon-publicBluesOther health carriersAll health carriers PremiumsPMPM3 Individual premiums PMPM were flat, overall, in2024 with reported average Individual marketpremiums of $555 PMPM, an increase of 0.1% from2023. Non-Public Blues experienced a decrease(-2.2%), while Public companies (3.9%) and OtherHealth Carriers (2.5%) sawincreases. Enrollment Overall enrollment increased an average of 27.1% in2024 relative to 2023 due to the continuation of theenhanced premium tax credits and shift of enrollmentfrom the Medicaid eligibility redetermination. PublicCompanies saw the largest increase at 39.7%, followedby Other Health Carriers (22.7%) and Non-PublicBlues(15.8%). Lossratio The reported overall loss ratio in 2024 increasedto 85.3%, a 0.9% increase from 2023. The

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