This time last year, a gaggle of buzzy health insurance startups justified big investments as key to their aggressive growth plans. Now, these same companies are pulling back and instead pursing a novel business strategy: earning profits.
“This was the first quarter where they talked about a little more rational approach,” said Gary Taylor, managing director and senior equity research analyst who covers healthcare facilities and managed care at Cowen.
Oscar Health will pause its full-service technology deals for the next 18 months. Clover Health plans to exit two Medicare Advantage markets. Bright Health Group in the process of raising outside capital.
These companies’ new focus reflects histories of unsustainable growth and investment, Taylor said. The startups went public with big valuations last year that have fallen at least 80%. Clover Health and Bright Health underperformed the technology sector at large: The Nasdaq’s QQQ index is down 18.5% so far this year, while Clover Health’s and Bright Health's shares declined 27.6% and 51%, respectively.
Oscar Health, Clover Health and Bright Health will need to raise outside funds to sustain their businesses, or they face acquisitions or bankruptcies, Taylor said. Because investors' interest in these companies has cooled, attracting capital will be more challenging and expensive than it would have been a year ago, he said.
“The cost of equity capital is higher, and the dilution from equity raises is larger, because the stock prices are lower,” Taylor said. “They’re going to have to shrink their way to profitability. Because the actions they’re going to take to push profitability de facto are going to position them worse in the marketplace, and they're going to lose some enrollment.”
These companies need to change the story they tell investors and prove they can control costs, said Erik Gordon, a professor at the University of Michigan Ross School of Business.
“You just can't say, ‘Look, we're just like Google, we're just like Facebook, we're just like Amazon.’ You can't point out a digitally native health insurer that has been around long enough to go through that cycle of growing into profitability,” Gordon said.
Oscar Health, Clover Health and Bright Health all faced the same problem: They grew too quickly, Taylor said.
Oscar Health and Bright Health focus on the individual market and the exchanges, and membership ballooned during the special enrollment periods President Joe Biden’s administration allowed as part of COVID-19 relief. That influx of new customers led to adverse selection. Clover Health, meanwhile, priced its products unsustainably to attract new members, and its technology platform didn't control medical spending, Taylor said.
“Some would say the jury's still out on how that's going to play out [for Clover], but obviously, in the near term, they've lost a lot of money on it,” Taylor said. “They really came at it from software is the solution to variation in healthcare spending. My view is that software is a tool, but it's not a solution. And the original premise of the company was entirely predicated on that.”
These insurtechs will need to seek above-market premium increases next year to maintain their operations, said Ari Gottlieb, a principal at A2 Strategy Group. He pointed to the Colorado market as an example: Bright Health's Colorado operation proposed a nearly 21% premium hike in the individual market for 2023, compared with Cigna’s 9.1% increase and Kaiser Foundation Health Plan’s 0.07% increase, according to federal data.
“It's the shift away from growth-at-all-costs to profitability, and it's because they're running out of money,” Gottlieb said.
There are two exceptions among the young health insurers: privately held Devoted Health and publicly traded Alignment Healthcare, two Medicare Advantage carriers eyeing big expansions for the 2023 plan year.
Devoted Health generated $7.7 million in net income from its insurance operations in the first half of 2022, although the company would have been in the red if it had not released a $32.7 million premium deficiency charge in 2021 in anticipation of this year’s losses, according to regulatory filings. Devoted Health, which also employs providers, only has to report financials for its Medicare Advantage division and its filings don't indicate whether the parent company is profitable. The insurer is seeking regulatory approval to enter eight states in 2023, according to a spokesperson.
Alignment Healthcare is seeking regulatory approval for the largest expansion in its nine-year history for the 2023 plan year. The company aims to enter Texas and Florida and expand its reach to 52 counties across six states. The company's shares closed at $15.90 on the Nasdaq Monday and is up 14% this year, in contrast to declining values among rival insurtechs and the digital health market at large. The Medicare Advantage insurer has lost $52.3 million so far this year.
“It's not gonna be a sustainable model to grab market share, and have that growth-at-all-costs mentality, that, frankly, the public markets were rewarding last year. Forget about profitability; they didn't care,” CEO John Kao said. “We knew that you can't do that. You have to profitably grow consistently, and make sure that your members have consistency and reliability of benefits. The other guys will give a lot of rich benefits one year and cut it way back the next year. That doesn't create reliability for patients and you’re going to lose market share.”
A timeline for insurtech profitability
Clover Health had aimed to achieve profitability excluding certain one-time costs in 2023. In February, CEO Vivek Garipalli said the company would be profitable next year according to non-generally accepted accounting principals. Garipalli announced in August he will step down as head of Clover Health at the start of next year. The company declined to provide specific guidance on when it would be profitable, but “we believe profitability and the generation of a free cash flow engine are in sight,” Chief Technology Officer Andrew Toy, who will succeed the outgoing CEO, wrote in an email. The insurtech has lost $179.4 million so far this year, which equates to $702.70 per member, the most among insurtechs. The company will need to raise $400 million by 2024 to sustain its business, according to Cowen.
Bright Health Group aims to break even on an EBITDA basis by 2024. In recent months, the insurtech has exited six markets, laid off 5% of its employees, increased its use of reinsurance and acknowledged it needs to raise capital. Bright Health lost $431.9 million during the first half of the year. “These conditions raise substantial doubt about the company’s ability to continue as a going concern,” Bright Health disclosed to the Securities and Exchange Commission in August. Bright Health did not respond to an interview request. The company will need to raise $1.8 billion by 2024 to stay afloat, according to Cowen.
Oscar Health aims to achieve profitability in 2025. The insurtech will pause full-service technology deals for the next 18 months as it seeks profitability for its insurance business next year and overall profitability in 2025. Oscar Health lost $189.4 million during the first half of the year. The company did not respond to an interview request. Oscar Health needs to raise $400 million to get to 2024, according to Cowen.