Oscar Health Inc

NYSE:OSCR

Earnings Call Analysis

Company Exceeds Guidance, Foresees 2024 Profit

Membership rose by 5% quarter-over-quarter, with full year premiums at $6.6 billion, slightly above projections despite a 3% decline from the previous year. Medical loss ratio improved significantly, landing at 81.6%, beating guidance. A combination of cost savings strategies and improved administrative efficiency saw insurance company adjusted EBITDA at $169 million, a $450 million year-over-year increase. Total company adjusted EBITDA marked a notable $417 million improvement. Looking ahead to 2024, revenue is expected to be between $8.3 and $8.4 billion, with total company adjusted EBITDA projected in the $125 to $175 million range, signaling a pivot to profitability.

Strong Finish in 2023 Sets the Stage for a Profitable 2024

The company exited 2023 with impressive results, showing key financial metrics surpassing expectations and achieving adjusted EBITDA profitability within the insurance business. A highlight was the fourth quarter's substantial gain—the medical loss ratio (MLR) improved significantly, and total company adjusted EBITDA saw a notable year-over-year advancement, indicative of a robust ending to the year.

Solid Membership Growth Amid Market Challenges

Membership grew modestly quarter-over-quarter, marking higher retention rates and special enrollment increases, despite a slight decrease in premiums. However, positive medical cost trends and operational efficiencies, including eliminating certain underperforming provider contracts, contributed to an improved full-year MLR and administrative expense ratio.

Substantial Financial Performance Improvements

Both the insurance company combined ratio and adjusted EBITDA saw significant year-over-year improvements, underpinned by better MLR and administrative cost efficiencies. The capital position remains robust, ending the year with substantial cash and investments, pointing to a financially healthy enterprise ready to support future growth.

New Financial Reporting Structure and 2024 Guidance

As part of its efforts to improve transparency and comparability, a new financial reporting framework will be introduced in the first quarter of 2024, focusing on total company performance indicators such as total revenue, MLR, and SG&A expense ratio. For 2024, the company eyes further improvement, projecting a profitable adjusted EBITDA, with anticipated total revenues of between $8.3 and $8.4 billion and continued reductions in MLR and SG&A expense ratios.

Pivot to Profitability Confirmed in 2023

The year 2023 served as a turning point where the company upheld its commitments for profitability within its insurance segment, embarking on a confident path that aims for total company profitability in the near future.

Experienced in Handling Special Enrollment Period Dynamics

Having dealt with special enrollment periods (SEPs) for years, the company has incorporated the related dynamics into its pricing models. As a result, SEP members have performed in accordance with past experiences, contributing positively to the company's growth and meeting expectations for 2024 despite the inherent risks of growing and acquiring new members.

Disciplined Pricing Strategy Distinguishes Market Stance

The company remains committed to disciplined pricing, acknowledging irrational behaviors seen in the industry during open enrollment. This approach led to substantial growth in rates aligning with market trends, positioning the company favorably amid market volatility and competitive pressures.

Healthy Cash Situation Fuels Positive Outlook for 2024

Looking forward to 2024, the company anticipates being cash flow positive and expects to use its strong capital position to fuel growth while managing parent cash balance effectively. This disciplined approach to financial management underlines the organization's strategic focus on sustainable growth.

Membership Dynamics Signal Market Strength

Member demographics indicate an influx of younger and, presumably, healthier individuals towards more silver plan enrolments—factors contributing to a healthier risk pool and expected higher risk transfers. Growth retention and strategic expansion in new and established markets demonstrate the company's effective market strategies.

Pharmacy Cost Management Set to Enhance 2025 Outlook

The company has intelligently structured its pharmacy benefits management (PBM) contract to achieve gradual cost reductions. This strategic planning is forecasted to result in lower pharmacy costs in 2025, ensuring incremental financial improvements over the next business cycles.

Earnings Call Transcript 2023-Q4

[Operator]

Good evening. My name is Bhavesh, and I'll be your conference operator today. At this time, I would like to welcome everyone to Oscar Health's Fourth Quarter and Full Year 2023 Earnings Conference Call. [Operator Instructions]

I will now turn the conference over to Chris Potochar, Vice President of Treasury and Investor Relations.

[Chris Potochar, executive]

Good evening, everyone. Thank you for joining us for our fourth quarter and full year 2023 earnings call. Mark Bertolini, Oscar's Chief Executive Officer; and Scott Blackley, Oscar's Chief Financial Officer, will host this evening's call. This call can also be accessed through our Investor Relations website at ir.hioscar.com. Full details of our results and additional management commentary are available in our earnings release, which can be found on our Investor Relations website at ir.hioscar.com.

Any remarks that Oscar makes about the future constitute forward-looking statements within the meaning of 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 quarterly report on Form 10-Q for the quarterly period ended September 30, 2023, filed with the SEC and other filings with the SEC, including our annual report on Form 10-K for the period ended December 31, 2023, to be filed with the SEC.

Such forward-looking statements are based on current expectations as of today. Oscar anticipates that subsequent events and developments may cause estimates to change. While the company may elect to update these forward-looking statements at some point in the future, we specifically disclaim any obligation to do so.

The call will also refer to certain non-GAAP measures. A reconciliation of these measures to the most directly comparable GAAP measures can be found in the fourth quarter and full year 2023 earnings press release available on the company's Investor Relations website at ir.hioscar.com.

With that, I would like to turn the call over to our CEO, Mark Bertolini.

[Mark Bertolini, executive]

Thank you, Chris. Good evening, everyone. When I joined Oscar, I highlighted 3 priorities for the business: one, achieve insurance company adjusted EBITDA profitability in 2023; two, achieve total company adjusted EBITDA profitability for 2024; three, continue to enhance the value of our technology to the +Oscar business and bring more of our capabilities to market.

We have made major progress towards achieving these priorities. We closed out 2023 with another strong quarter, driving financial performance for the full year and achieving the first of our priorities. The insurance company generated $169 million of adjusted EBITDA profitability in 2023, a milestone Oscar committed to in early 2022. Our medical loss ratio improved 370 basis points year-over-year to 81.6%, below the low end of our guidance range.

For the full year, overall claims trends were favorable relative to our expectations. Utilization trends by category remain consistent throughout the year with inpatient performance in line; outpatient and pharmacy, slightly above; and professional, well below.

Total company adjusted EBITDA improved by $417 million versus the prior year to a loss of $45 million. Our strong momentum positions us well to achieve the second priority I mentioned, total company adjusted EBITDA profitability in 2024.

Our business is well positioned for sustainable long-term growth and margin expansion. We exceeded our 2024 open enrollment expectations and expect to serve over 1.3 million members. We continue to see strong retention, which we believe is driven by our superior member experience.

Our disciplined pricing for 2024 is allowing us to grow our membership well above the market while driving margin expansion. We expect another year of MLR improvement given our pricing strategy and total cost of care initiatives, including significant PBM savings and enhanced payment integrity efforts. We also anticipate continued operational cost improvement, including vendor savings from our enhanced scale and the benefit of operating leverage as we return to growth.

Finally, our technology is making the health care experience more seamless for over 1 million Oscar members, the 500,000 client lives we now serve through +Oscar and the providers who care for them.

Overall, 2023 was an exceptional year for Oscar. We are delivering on our commitments and are on a solid path to deliver sustained growth with improved margins.

Now I will turn to our business highlights. This past open enrollment marked Oscar's 11th year as a prominent player in the ACA market. We expanded into 165 new counties and are now privileged to serve over 1.3 million members across 20 states. Our above-market growth was driven by strong retention and new members in both existing and expansion markets. Consumers choose us for our affordable and innovative plan designs and they stay with us for our superior member experience. Our NPS continues to be an industry-leading 60.

We continue to grow in key states for Oscar, including Florida, Georgia, and Ohio. We also outperformed our expectations in new service areas, including Cincinnati, West Central Tennessee, Topeka, and Iowa. We believe our superior member experience is meeting members' needs and continue to demonstrate we can launch and succeed in new markets outside of major metropolitan areas.

We introduced new products to meet the needs of our fast-growing and diverse member population, including expanding our chronic illness plans, diabetes care, and Breathe Easy to new markets. We also launched an enhanced Spanish first experience to deliver culturally authentic experience to our growing Spanish-speaking member base.

Consumers expect a level of convenience and accessibility in health care comparable to the best consumer companies in the U.S. Oscar makes this experience possible through our full stack technology. Since inception, Oscar has been focused on building our technological infrastructure and end-to-end experience. We believe this stack offers greater control over the member experience, engagement and affordability.

Our platform has fueled major strides in operational efficiency. We launched powerful capabilities to digitalize more interactions with providers and members and automate a growing number of clinical and administrative workflows via AI-powered features.

As an example, we leveraged automation to support members more effectively and efficiently during open enrollment. We enhanced our member services IVR and launched an AI-powered secure messaging feature. Self-service features like these make it faster and easier for members to get the answers they need and allow our care team to support more complex member needs. While membership increased this open enrollment, call volume remains steady, call abandonment rates decreased and member satisfaction increased.

We are making our superior member experience and innovative technology available to others in the health care system, enabling a higher quality experience for consumers and driving better engagement outcomes and business performance for clients.

We are pleased with the traction of Campaign Builder plus Oscar's engagement and automation platform. Campaign Builder now serves approximately 500,000 client lives in addition to the 1.3 million members enrolled in Oscar Health Insurance. Campaign Builder clients saw impressive results in the second half of 2023. One payer client saw a retention rate of over 96% for Medicare Advantage members engaged with the retention program. A diabetes care gap program for another client resulted in over 40% of the eligible population, completing a preventative diabetes screening within 90 days of engaging with the campaign. We are encouraged with these proof points and committed to bringing more capabilities to market to power more of the health care system.

As we have shared on prior calls, AI continues to be a part of our overall strategy to ensure our technology can deliver a superior member experience, improve health outcomes, meet provider needs and lower costs. We continue to build AI use cases, including integrating OpenAI's GPT technology into Campaign Builder. We believe our AI-powered tools can be easily incorporated into client workflows to support their strategic business objectives and patient needs.

Our outperformance in 2023 sets a solid foundation for us to deliver on our target for total company adjusted EBITDA profitability in 2024. Our strategic priorities include: one, running a great company with market-leading sustainable, scalable operations; two, continually investing in our superior member experience; three, harnessing our technology to power others; and four, continuing to innovate market offerings to extend beyond the ACA.

Our strategic priorities also include the long-term growth opportunity we see in the individual market and the potential we see to serve a broader set of customers, including employers and employees. The ACA is the fastest-growing segment of health insurance with over 21 million people enrolled in individual insurance plans on exchanges for 2024. Oscar is well positioned to capitalize and innovate on the strong market growth as well as leading the industry in trends driving the future of health care.

Oscar was purpose-built with a focus on accessibility, affordability and a superior member experience. Member experience is in our DNA. We believe we are best positioned to win in an increasingly digital and consumer-centric marketplace. We look forward to sharing more on our long-term strategic plan at our next Investor Day in June in New York.

With that, I will turn the call over to Scott.

[Richard Blackley, executive]

Thank you, Mark, and good evening, everyone. We delivered strong financial results in each quarter of 2023 with most core metrics exceeding our expectations for the full year. We delivered on our commitment for insurance company adjusted EBITDA profitability in 2023 and have a clear line of sight into achieving total company adjusted EBITDA profitability this year. I will touch on a few fourth quarter highlights before shifting to our full year performance.

We had a strong close to 2023. Our fourth quarter medical loss ratio significantly improved by 520 basis points to 86.4%. And our fourth quarter total company adjusted EBITDA loss was $112 million, a $78 million year-over-year improvement. We ended the year with approximately 1 million members. Membership increased 5% quarter-over-quarter, driven by higher retention due to lower lapse rates and increased special enrollment additions.

Turning to the full year. Direct and assumed policy premiums were approximately $6.6 billion, a 3% decrease year-over-year and modestly above the high end of our guidance range. This was driven by lower membership, partially offset by rate increases. The full year medical loss ratio was 81.6%, a 370 basis point year-over-year improvement and below the low end of our guidance range.

Overall utilization trends were modestly favorable relative to our expectations for the full year, and we delivered medical cost savings through our total cost of care initiatives. As Mark mentioned, utilization trends within specific service categories remain consistent throughout the year.

On risk adjustment, our risk transfer as a percentage of direct and assumed policy premiums for 2023 was lower year-over-year at approximately 14% due to our member profiles having shifted closer to the overall ACA population. The December Wakely report resulted in only modest updates to our risk transfer estimates.

Switching to administrative costs. The 2023 insurance company administrative expense ratio improved 270 basis points year-over-year to 17.9%, driven by distribution optimization and lower risk transfer per member as a percent of premiums compared to the prior year. Partially offsetting these positive developments was a $29 million provision for credit losses on risk sharing receivables, which mainly impacted the fourth quarter. This relates to a small number of provider risk deals, which have since been terminated.

The 2023 insurance company combined ratio significantly improved by approximately 640 basis points year-over-year to 99.5% driven by both an improved MLR and administrative cost efficiencies. In 2023, we achieved insurance company adjusted EBITDA of $169 million, representing a $450 million year-over-year improvement, and that was above the high end of our guidance range.

Our adjusted administrative expense ratio improved 350 basis points year-over-year to 21% for the full year, in line with our expectations. The lower adjusted administrative expense ratio was driven by the same factors that impacted the insurance company administrative ratio as well as higher net investment income.

We have made significant progress on improving our profitability. Our full year total company adjusted EBITDA was a loss of $45 million, a substantial $417 million year-over-year improvement and better than the high end of our guidance range. Over the past 2 years, adjusted EBITDA, as a percentage of premiums before ceded reinsurance, has improved by approximately 15 points.

Shifting to the balance sheet. Our capital position remains very strong. We ended the year with $2.9 billion of cash investments, including $234 million of cash and investments at the parent. As of December 31, 2023, our insurance subsidiaries had approximately $800 million of capital and surplus, including $248 million of excess capital driven by our strong operating performance. As a reminder, the higher capital requirements for new carriers in Florida, our largest state, expired for us at the start of this year.

As of January 1, 2024, we expect a lower capital ratio requirement to generate an additional $140 million of excess capital in our insurance subsidiaries. Given the excess capital in our insurance subsidiaries, funding of our 2024 growth capital requirements will have minimal impact on parent cash. With respect to quota share reinsurance, in 2024, we expect to increase our ceding percentage from around 45% of premiums before ceded reinsurance to the low 50% range.

Before I turn to the 2024 outlook, I want to discuss a new financial reporting structure that we will roll out beginning with our first quarter 2024 results. In order to increase transparency and improve comparability, we will be revising our presentation of the income statement to more closely align with our peers, and our discussion of financial results and guidance will focus on the performance of the total company.

For 2024, we will provide guidance for total revenue, medical loss ratio, SG&A expense ratio and total company adjusted EBITDA. In today's earnings release, we included supplemental information on the 2024 financial outlook, including full year 2023 results for these measures as well as details on the components of the metrics and calculations.

Turning now to the 2024 full year guidance. We expect to build on the strong momentum in 2023 and achieve total company adjusted EBITDA profitability in 2024. We expect total revenues in the range of $8.3 billion to $8.4 billion based on strong retention, above-market growth during the 2024 open enrollment period and SEP member additions throughout the year as Medicaid redeterminations continue.

On Medicaid redeterminations, our 2024 guidance contemplates strong SEP additions and assumes higher acuity and partial year risk adjustment dynamics for these members. We are pleased with our strong open enrollment growth and expect it to result in, overall, a healthier membership profile.

We expect our medical loss ratio to be in the range of 80.2% to 81.2%, representing a 90 basis point improvement year-over-year at the midpoint. For 2024, we priced for medical cost trends and expect MLR improvements to be driven by our total cost of care initiatives, including PBM savings. We expect our quarterly MLR seasonality to be similar to 2023, although with a steeper slope.

For 2024, we expect a higher risk transfer as a percentage of premiums as compared to 2023 based on our updated membership mix. As the new policy year business matures, our overall per member claims levels may change with corresponding impacts on our estimate for risk transfer. Such changes impact the numerator and denominator of our MLR, but we would not expect them to have an impact on our per member underwriting economics.

We expect our SG&A expense ratio to be in the range of 20.5% to 21%, representing a 350 basis point year-over-year improvement at the midpoint. This ratio includes stock-based compensation expense, which, in 2023, was approximately $160 million and included a onetime charge of $46 million related to accelerated stock-based compensation expense recognized as a result of the cancellation of the founders awards.

We expect our SG&A expense ratio to be fairly consistent in the first 3 quarters with a modest uptick in the fourth quarter. We expect total company adjusted EBITDA to be in the range of $125 million to $175 million, representing an almost $200 million year-over-year improvement at the midpoint.

In closing, 2023 was a pivotal year for Oscar. We delivered on our commitments for insurance company adjusted EBITDA profitability, and we are well positioned to return to growth and achieve total company adjusted EBITDA profitability this year.

And with that, let me turn the call back over to Mark for closing remarks.

[Mark Bertolini, executive]

Thank you, Scott. I would like to close by looking back at the financial metrics we shared with analysts in connection with Oscar's initial public offering in 2021. We said we expected to achieve the following in 2023: nearly 1 million members; $5.7 billion in direct and assumed policy premiums; an 83% MLR; and a total company adjusted EBITDA loss of $222 million.

Today, Oscar has far exceeded these metrics. We are a prominent player in the fastest-growing segment of health insurance. We demonstrated the power of our superior member experience and technology by exceeding our projections for open enrollment. We achieved insurance company profitability and outperformed our expectation for total company adjusted EBITDA in 2023. We are returning to growth and have a clear line of sight into delivering on our target for total company adjusted EBITDA profitability in 2024.

We have done what we said we would do. Oscar is delivering on its commitments. I would like to thank the Oscar team. We are powered by our people. Their hard work and dedication make all of this possible.

With that, I would like to turn the call over to the operator for the Q&A portion of our call.

[Operator]

[Operator Instructions] Our first question comes from the line of Adam Ron of Bank of America.

[Adam Ron, analyst]

Congrats on the strong results. In thinking about the adjusted EBITDA trajectory from here, you're on track to do something like 2% from a margin perspective in 2024. And I think in the past, you've talked about total company maybe on a pretax basis being closer to 5%. And so the difference between those 2 things is still roughly 300 to 500 basis points of margin improvement. And this year was sort of outsized from a revenue growth perspective.

And so what do you see as like the major levers in terms of being able to close that gap between the 2% adjusted EBITDA and 5% pretax margin given you probably shouldn't expect to kind of like 40% revenue growth here from here and maybe some of the lower hanging fruit around PBM contract renegotiation aren't as readily available. And so just thinking about what the major levers are from here would be helpful.

[Mark Bertolini, executive]

Thanks, Adam, Mark Bertolini here. We'll start with big categories. First, we have enough fixed cost to grow to a much larger size. So fixed cost leverage will be pretty robust no matter how much we grow, although we anticipate and continue to anticipate that 20% growth year-over-year is achievable.

Secondly, we have in our variable operating expense, been able to leverage large language models on the back end of the system. And just for an extra data bit on our call volumes, we actually handled the call volumes we had this year with 200 less people answering the phones. So we continue to see big operating opportunities on the variable cost side.

We are in the midst of looking at provider contracts, particularly hospital contracts, and we now have a matrix of contracts that we need to get to optimal level from the standpoint of both terms and rates. And so we have a list based on renewals and market size where we're going to begin those conversations with our provider partners, not just because we have more market share, but because we have better relationships with them and the way we deal with them day in and day out on utilization management and our reimbursement and paying claims.

Scott, anything to add?

[Richard Blackley, executive]

Yes. Adam, I think that we certainly think there is room to run in terms of continuing to drive MLR performance through disciplined pricing and we see continued opportunity to drive total cost of care down, allowing us to both grow and to take margin.

Mark talked about admin efficiency. I think there's also plenty of room for us to continue to drive favorable performance there. And then I think that just broader speaking, we really believe that this market is going to continue to attract individualize consumers. And that's where we really shine, on building innovative plans. And if we can continue to see that development in the market, we think that we have a terrific opportunity to continue to grow the company. Obviously, fixed cost leverage is going to be our friend. So we think we've got all the bones in place to get to that over time.

[Adam Ron, analyst]

Awesome. If I could just sneak one more in, maybe more shorter term. Both CVS and Cigna have been seeing somewhat varied performance on the exchanges as opposed to you, [ Centia ] and Molina and I think CVS in particular, has been complaining about the special enrollment charges or having less of an opportunity to risk code members who joined in the middle of the year, and that's something that Oscar has struggled with in the past but doesn't appear to be impacting results this year.

And so you if you could just square that commentary of like are you seeing outsized pressure from this mid-year enrollment dynamic? And does that argue that core MLR results are higher than what's been reported? And is that how we should contemplate 2025 MLR improvement from here? Just wanted to understand the varied performance versus some of your competitors.

[Richard Blackley, executive]

Look, I think that we've been experienced SEP for years. We certainly understand the dynamics of how duration factors impact those members. We've built that into our price assumptions. This year, we've seen SEP members that have performed more or less consistent with our historical experience with them. So nothing for us that has caused us any challenges in terms of onboarding those members.

With respect to 2024, we assumed that we would be growing. The SEP membership would come in into the second half of the year, and we built that into our guidance for MLR. It's an area that's challenging, certainly. But we've got experience there. We've got, I think, a reasonable expectation of how those members are going to perform based on what we've seen through the end of the year and into this year. And they have a morbidity and profile that is kind of what we're expecting.

So there's always some risk with growth and with new members, but we think that we've built those rest into the guidance that we gave you today.

[Operator]

Our next question comes from the line of Josh Raskin from Nephron Research.

[Joshua Raskin, analyst]

Do you think the stability of the exchanges and certainly the growth that we're seeing in the market is attracting sort of these new larger competitors? Are you seeing overall rational behavior from them? And how lasting do you think the competition is?

[Mark Bertolini, executive]

I would say that rational behavior was not necessarily in place last year. And I would -- in 2023, in open enrollment for 2023, in large part because people have not priced accordingly to how the market works. I mean, as you well know, and part of what we found even when I was with Aetna in the markets is that the minimum loss ratios that were put in place for pricing don't allow you to underprice and then price up business after you get share because you have to give back rebates.

And so going into with a mindset that we will grow with disciplined pricing is an important piece. And we saw some of that this year for 2024 open enrollment, where people took their prices up, lost the business, and Georgia is one of those markets. And when we look at our rates in those markets, we are where everybody else is now pretty much with increases that are in the 8% to 9% range.

So we felt that -- we go into this with open eyes and deep understanding of this market over time, and we believe that we have priced accordingly and have been disciplined about it. Stable and rational pricing.

[Joshua Raskin, analyst]

Got you. And then just secondly, midpoint of EBITDA guidance of $150 million at the holdco level, what does that mean for cash flow from operations? And can you just help us with the moving parts on the parent cash balance for 2024?

And sort of thinking about the Florida capital that's not needed sort of versus the growth. I'm just trying to figure out what we should be thinking about cash flow from operations and then what does that mean for parent cash.

[Richard Blackley, executive]

Yes. So Josh, I think that the importance of the adjusted EBITDA metric for total company is that, that would -- with the growth, we'll be getting additional cash prior to paying the risk transfer estimate. So we would anticipate that the total company will be cash flow positive. We'll be building capital in our insurance subsidiaries.

And in terms of those subsidiaries, what we would be looking to do going forward is prioritizing, one, funding the growth that we hope to continue to have; two, distributing capital to the parent to offset parent expenses; and three, that they will be absorbing more of the holding company costs over time.

So we feel like we've got a good situation with capital and cash and would expect to be cash flow positive next year -- or excuse me, in 2024.

[Operator]

Our next question comes from the line of Nathan Rich from Goldman Sachs.

[Nathan Rich, analyst]

Congrats on the strong quarter. I maybe wanted to start by asking if you could maybe break down the composition of membership growth a little bit more between markets that maybe you entered for 2024 versus growth within existing markets. And you also talked about a healthier membership base. Could you maybe just expand on what you're seeing there?

[Richard Blackley, executive]

Yes. Well, why don't I start, and then Mark can maybe talk about some of the membership growth. But overall, when we look at the demographics and kind of the morbidity of the group that we're seeing, I would characterize it as, number one, it's younger. And so we certainly, with this growth, have seen younger members coming in more than -- a little more than a year younger in terms of the total population.

Number two, I would characterize it as we've seen a shift of more of our membership in 2024 towards bronze -- or excuse me, from bronze towards silver. And so that is another dynamic that we've seen.

Overall, I would say that our membership being healthier is representative of the fact that we think we're going to have a higher risk transfer this year. So the dynamics of that membership, younger, healthier and in silver plans are probably the things I would kind of point out.

Mark, do you want to cover the state by state?

[Mark Bertolini, executive]

Sure. Strong retention was the biggest part of our growth. I would say that. And also provide stabilization and risk adjustment as we go forward into this year. It was obviously helpful for us last year. We did grow new members in existing markets, Georgia, Florida, Ohio, Tennessee, Iowa, and Missouri. But we also outperformed expectations in new markets where we did some service area expansion, Cincinnati, Tennessee and some of the rural markets in Iowa and Georgia.

[Nathan Rich, analyst]

Great. And maybe just a quick follow-up. I think in the past, the company has talked about a target MLR in the low 80% range. You pretty much guided to that level for 2024.

So I guess as we think beyond this year, do you think there's still kind of improvement in the MLR that can be had? Or will more of the margin expansion, I guess, come from leveraging growth that you might see?

[Mark Bertolini, executive]

We definitely have room in the MLR.

[Richard Blackley, executive]

I mean, Steven put a fine on that. Remember, our PBM contract has year-over-year step improvements that are built into that contract. So without doing anything, our pharmacy costs would be lower in 2025. So a lot of the things that you're seeing in the run rate that's benefiting '24, we would anticipate to have incremental improvements into '25, and we would expect to continue to drive down the cost of health care.

[Operator]

[Operator Instructions] Our next question comes from the line of Stephen Baxter from Wells Fargo.

[Stephen Baxter, analyst]

I just wanted to follow up on the PBM discussion. I know in the past, you talked about the savings being spread out over 2024 and 2025. So good to hear some of that still in front of you. Can you give us a sense of maybe what inning we're in, in the PBM savings exiting 2024?

And then just a second on kind of the profile of membership you're looking for in 2024. Just wondering, it sounds like now that you've gotten to insurance company profitability, I would think that growth that you're seeing from inside the open enrollment period would seemingly come on at incremental profitable margins, but perhaps you're taking a more conservative stance to start out. So would love some insight into how you're thinking about the profitability of the growth.

And then just last one. Exiting this year, where do you think you'll be on some of the payment integrity efforts that you've talked about in the past?

[Richard Blackley, executive]

I'm going to try to remember all those, so if we miss one, and I'm not being -- please come back. So when I think about where we might be going from a overall starting with kind of the MLR, I think there's opportunities there around the PBM, where the PBM actually goes out until 2026. And so we have a contract where each year, we will see benefits. And this was -- the first year was the largest step change, but there continue to be meaningful improvements in that contract over the remaining term. So that is -- that's something that we can put in the bank, and we're pleased with our partnership there with our provider.

[Mark Bertolini, executive]

And I would add that we also have the opportunity for volume. More volume gets us more discounts than we initially anticipated. And then thirdly, there's an opportunity to work on the MAC list quarter after quarter.

On the payment integrity issues. We will see full year effect on what we've done for last year this year, but we have more to go this year. So we'll continue to improve upon those, particularly as we apply AI models to the back of the business and go after things that we now pay vendors for.

And then I think last but not least, we still have a lot of provider relationships that we can affect in markets that were vintage markets where the company started, had no volume and was able to move on those medical costs. So we have room on medical cost across the board.

[Richard Blackley, executive]

And then, Steve, probably the last piece on your question on member economics. I would say that we would anticipate that all of the growth that we're seeing in open enrollment is contribution margin positive. So at this point, growth is great for the bottom line.

We also expect to see continued enrollment through the special enrollment period. And while those members come at a -- we talked about this in the past with about a 10% higher MLR and there are other durational impacts that we talked about. That's in the first year, and then they look exactly like the rest of OE if we can retain those people. So it is certainly the case that depending on when you get those members in the year, the economics can be challenging in the first year, but we built that into the plan. So those are already built into our guidance.

And we are excited to have the opportunity to add more members through special enrollment period in addition to the success that we've already had in open enrollment.

[Operator]

Our next question comes from the line of Adam Ron of Bank of America.

[Adam Ron, analyst]

I just have one more question. I get a lot of questions on the Affordable Care Act subsidies, and there are some government estimates out there if the subsidies were to go away, what would happen to the market size.

And so just wondering, one, if you have any comments on what you'd expect it to do to the market maybe relative to like what your mix of members look like relative to who is using a PTC. So first on that.

And second, you mentioned before you look at G&A, it's fixed versus variable. Like maybe this would be a helpful framework for us of if we're able to think about how much of the G&A is fixed versus variable, how that would flow into earnings. And then finally, if the subsidies were to go away, which obviously nobody can predict, is it fair to say that margin would degrade? Or is there a reason to believe there's some levers you could pull to kind of offset that?

[Mark Bertolini, executive]

Well, the last part of your question, Adam, we believe that we have an opportunity to provide services at a different price point that could help folks when and if the enhanced subsidies go away. But going up to the more general level of will they, we had some interesting look at our data this open enrollment. And in this open enrollment, 63% of new ACA consumers are from red states and 76% during the open enrollment and year-over-year in the ACA, our market growth is in red states.

So I kind of find it hard that the political dynamic that was going on 6, 8 years ago is going to be the same relative to the Republican party going after a group of people that largely are going to be their own constituents. We'll see. We have a planning version on our strategic plan of having it go away and all the things that we would need to do with product in order to make things affordable. Folks in the group we worry about most are the people in the 100% to 200% federal poverty level that have 0 premium plans and would potentially be paying somewhere around $60 or $70 a month.

That's the place where we think the impact is. And we're planning against that, defined solutions for it. Relative to fixed versus variable, Scott, I'll let you to summarize...

[Richard Blackley, executive]

Look, on fixed versus variable, I think that's information that we will look forward to sharing more about with you when we have our Investor Day in June.

[Operator]

As we have no further questions at this time, we will conclude today's conference call. We thank you for participating, and you may now disconnect.