U.S.

Health Insurance Industry | 2023 Mid-Year Results

U.S. Health Insurance Industry Analysis Report

HEALTH INDUSTRY OVERVIEW
Table 1 below provides a 5-year quarterly snapshot of the U.S. Health
Inside the Report Page No.
insurance industry’s aggregate financial results for health entities who file
Industry Overview ................................... 1
with the NAIC on the health quarterly statement blank. The health
Net Earnings ............................................ 2
insurance industry reported a 6% decrease in an underwriting gain to over Underwriting Results..........................2 – 3
$17 billion from over $18 billion for the same period in the prior year. Impact of Changes in the Health
However, net income increased 6% to over $18 billion for the first six Insurance Market .................................... 3
months of 2023 compared to the same period in the prior year. The Enrollment.......................................... 4 - 5
industry’s profit margin decreased modestly to 3.3% from 3.4%, while the Premium Revenues ............................ 6 - 7
Liquidity................................................... 8
combined ratio increased by a modest one-half basis-point.
Capital and Surplus ................................. 8
Notable items as compared to second quarter 2021 include the following:
• Net earned premium increased 7% ($37 billion)
• Hospital & medical expenses increased 8% ($36 billion)
• Administrative expenses increased 7% ($4 billion)
• Enrollment increased 5%
• Cash flow from operations was $66 billion
• Capital and surplus increased 6% ($12 billion) to over $213 billion from $201 billion at December 31, 2022

Table 1
Financial Summary: June 30, 2023 - 2019
(In Millions) Chg. 2Q 2023 2Q 2022 2Q 2021 2Q 2020 2Q 2019
Direct Written Premium 6.7% $543,812 $509,645 $448,705 $410,736 $379,925
Net Earned Premium 7.3% $539,571 $502,910 $444,109 $406,706 $374,079
Net Investment Income Earned 97.4% $5,853 $2,966 $2,735 $2,712 $3,145
Underwriting Gain/Loss (5.9)% $17,517 $18,625 $16,268 $23,717 $15,237
Net Income/Loss 6.0% $18,244 $17,210 $16,805 $21,543 $16,876
Total Hospital & Medical Exp. 8.3% $465,662 $429,818 $380,438 $326,101 $318,456
Loss Ratio 0.6 pts 85.6% 85.0% 85.3% 80.2% 84.7%
Administrative Expenses 6.8% $61,054 $57,168 $49,391 $57,558 $42,431
Administrative Expense Ratio (0.1) pts 11.2% 11.3% 11.1% 14.1% 11.3%
Combined Ratio 0.5 pts 96.8% 96.3% 96.4% 94.2% 95.9%
Profit Margin (0.1) pts 3.3% 3.4% 3.7% 5.3% 4.5%
Enrollment 4.6% 274 262 251 238 233
Premium PMPM 3.5% $332 $321 $296 $283 $273
Claims PMPM 4.2% $286 $275 $254 $229 $233
Cash Flow from Operations 151.2% $66,155 $26,334 $12,175 $38,343 $18,808
# of Companies Filed (6) 1,157 1,163 1,131 1,096 1,048
6-mo. Chg. 2Q 2023 2022 2021 2020 2019
Capital & Surplus 5.9% $213,360 $201,488 $191,312 $176,334 $155,944

*All figures only include health entities that file financial statements with the NAIC.
Note: Adjustments to exclude affiliated amounts were made where appropriate.

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 U.S. Health Insurance Industry | 2023 Mid-Year Results

NET EARNINGS
Net income increased 6% to over $18 billion from just over
$17 billion for the first six months of 2023 compared to the
same period in the prior year. However, the Industry
reported a 6% ($1 billion) decrease in underwriting gains
and a 25% ($863 million) increase in federal income taxes
incurred. The increase in net income can be attributed to a
$3 billion increase in net investment income earned partially
offset by a 25% ($863 million) increase in federal income
tax.

Figure 1 illustrates the trend in profitability and reflects a

profit margin of 3.3% through the second quarter of 2023
which is a modest decrease from 3.4% for the same period
in 2021.

UNDERWRITING RESULTS
As indicated on Table 1, the decrease in the industry’s
underwriting results can be attributed primarily to an 8%
($36 billion) increase in total hospital and medical
expenses to $466 billion through the first six months of
2023 from $430 billion for the same period of 2022. The
industry also reported a 7% ($4 billion) increase in claims
adjustment and administrative expenses to $61 billion
from $57 billion resulting in a modest decrease in the
administrative expense ratio. The industry partially offset
these expenses with a 7% ($37 billion) increase in net
earned premium.

Figure 2 illustrates the increase in total hospital and

medical benefits for the first six months of 2023 as
compared to the prior year period. Historically, the
Industry’s loss ratio had fluctuated slightly while reporting
consistent increases in hospital and medical benefits.
However, with the onset of the COVID Pandemic during
2020 and lingering throughout 2021, the aggregated loss
ratio dropped to 80% in 2020 before returning to pre-
COVID levels at 85% in 2021 and 2022.

Figure 3 illustrates the comparison in claims adjustment

and administrative expenses through the second quarter
of 2023 and the four prior years.

The increase in the loss ratio and the modest decrease in

the administrative expense ratio culminated in a one-half
basis-point decrease in the combined ratio.

The Federal Reserve increased the federal funds interest

rate seven consecutive times during 2022 from 0.25%
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 U.S. Health Insurance Industry | 2023 Mid-Year Results

prior to March 15, 2022, to 4.5% by December 14, 2022. The Federal Reserve continued to increase the interest rate
four more times during the first half of 2023 to 5.25%, which is the highest in sixteen years.

Table 2 below provides data from the Exhibit of Premiums, Enrollment, and Utilization by Line of Business. The table
includes comparison of direct and earned premium, claims, loss ratio, net premium and claims per member per month,
and enrollment through the second quarter of 2023 and the four prior years.
Table 2
Exhibit of Premiums, Enrollment & Utilization by Lines of Business
Individual Comprehensive Group Comprehensive
Hospital & Medical 2Q 2023 2Q 2022 2Q 2021 2Q 2020 2Q 2019 # Hospital & Medical 2Q 2023 2Q 2022 2Q 2021 2Q 2020 2Q 2019
(In Millions, Except PMPM) (In Millions, Except PMPM)
Direct Written Premium $53,807 $47,979 $41,421 $38,978 $39,535 Direct Written Premium $85,077 $84,585 $83,042 $83,226 $83,686
Net Earned Premium $51,833 $47,506 $39,816 $37,170 $38,084 Net Earned Premium $84,757 $84,335 $82,851 $82,587 $83,971
Total Hospital & Medical Exp $40,737 $37,019 $31,356 $26,734 $27,331 Total Hospital & Medical Exp $71,717 $70,966 $70,197 $65,097 $67,869
Loss Ratio 78.6% 77.9% 78.8% 71.9% 71.8% Loss Ratio 84.6% 84.1% 84.7% 78.8% 80.8%
Net Premium PMPM $534 $528 $508 $498 $521 Net Premium PMPM $544 $519 $492 $470 $467
Claims PMPM $420 $411 $400 $358 $374 Claims PMPM $460 $417 $370 $377 $364
Margin $114 $114 $117 $108 $140 Margin $84 $102 $122 $92 $103
Enrollment 16 15 14 13 12 Enrollment 26 27 28 29 30

Medicare Supplement 2Q 2023 2Q 2022 2Q 2021 2Q 2020 2Q 2019 # Vision 2Q 2023 2Q 2022 2Q 2021 2Q 2020 2Q 2019
(In Millions, Except PMPM) (In Millions, Except PMPM)
Direct Written Premium $6,908 $6,571 $6,318 $6,122 $5,782 Direct Written Premium $1,536 $1,473 $1,408 $1,365 $1,279
Net Earned Premium $6,861 $6,492 $6,227 $6,023 $5,404 Net Earned Premium $1,534 $1,472 $1,408 $1,357 $1,353
Total Hospital & Medical Exp $5,886 $5,218 $4,850 $4,391 $4,743 Total Hospital & Medical Exp $1,687 $1,532 $1,477 $1,085 $1,383
Loss Ratio 85.8% 80.4% 77.9% 72.9% 87.8% Loss Ratio 109.9% 104.1% 104.9% 80.0% 102.2%
Net Premium PMPM $216 $214 $210 $212 $211 Net Premium PMPM $6 $6 $6 $6 $6
Claims PMPM $186 $172 $164 $155 $174 Claims PMPM $7 $6 $7 $5 $7
Margin $31 $42 $47 $57 $37 Margin ($1) ($0) ($0) ($1) ($0)
Enrollment 5 5 5 5 5 Enrollment 42 39 38 37 36

Dental 2Q 2023 2Q 2022 2Q 2021 2Q 2020 2Q 2019 # FEHBP 2Q 2023 2Q 2022 2Q 2021 2Q 2020 2Q 2019 #
(In Millions, Except PMPM) (In Millions, Except PMPM)
Direct Written Premium $8,130 $7,721 $7,392 $6,719 $7,008 Direct Written Premium $23,318 $22,419 $21,491 $20,059 $19,872
Net Earned Premium $7,683 $7,277 $7,005 $5,878 $6,405 Net Earned Premium $24,502 $22,310 $21,848 $20,276 $20,342
Total Hospital & Medical Exp $6,857 $6,329 $6,002 $4,144 $5,454 Total Hospital & Medical Exp $22,799 $20,675 $20,167 $18,222 $18,920
Loss Ratio 89.2% 87.0% 85.7% 70.5% 85.2% Loss Ratio 93.0% 92.7% 92.3% 89.9% 93.0%
Net Premium PMPM $27 $27 $26 $24 $26 Net Premium PMPM $445 $408 $401 $378 $388
Claims PMPM $24 $23 $23 $17 $22 Claims PMPM $414 $378 $370 $339 $361
Margin $3 $3 $4 $7 ($1) Margin $31 $30 $31 $38 $27
Enrollment 47 45 45 42 42 Enrollment 9 9 9 9 9

Medicare 2Q 2023 2Q 2022 2Q 2021 2Q 2020 2Q 2019 # Medicaid 2Q 2023 2Q 2022 2Q 2021 2Q 2020 2Q 2019 #
(In Millions, Except PMPM) (In Millions, Except PMPM)
Direct Written Premium $196,990 $172,500 $141,713 $126,752 $110,031 Direct Written Premium $160,734 $156,257 $134,720 $118,435 $102,326
Net Earned Premium $197,697 $172,187 $141,285 $125,079 $109,768 Net Earned Premium $160,675 $155,688 $132,903 $113,488 $100,181
Total Hospital & Medical Exp $167,325 $143,454 $121,156 $97,530 $90,945 Total Hospital & Medical Exp $139,076 $128,676 $113,412 $96,841 $90,872
Loss Ratio 84.6% 83.3% 85.8% 78.0% 82.9% Loss Ratio 86.6% 82.6% 85.3% 85.3% 90.7%
Net Premium PMPM $1,284 $1,197 $1,123 $1,100 $1,052 Net Premium PMPM $445 $448 $425 $423 $392
Claims PMPM $1,087 $997 $963 $858 $871 Claims PMPM $385 $370 $363 $361 $356
Margin $197 $200 $160 $242 $180 Margin $60 $78 $62 $62 $36
Enrollment 26 24 21 19 18 Enrollment 60 59 54 48 44

Other Health 2Q 2023 2Q 2022 2Q 2021 2Q 2020 2Q 2019 #

(In Millions, Except PMPM)
Direct Written Premium $11,596 $11,212 $10,549 $10,861 $10,283
Net Earned Premium $11,599 $11,090 $10,640 $11,157 $10,625
Total Hospital & Medical Exp $12,579 $11,041 $10,606 $11,092 $9,630
Loss Ratio 108.5% 99.6% 99.7% 99.4% 90.6%
Net Premium PMPM $50 $50 $47 $50 $52
Claims PMPM $54 $49 $46 $50 $47
Margin ($4) $0 $0 $0 $5
Enrollment 43 38 38 38 38

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 U.S. Health Insurance Industry | 2023 Mid-Year Results

The CDC has reported over 6 million hospitalizations from COVID-19 nationwide and over one million deaths since
January 21, 2020. The health insurance industry reported a 43% ($140 billion) increase in health benefit claims incurred
between June 30, 2020, and June 30, 2023. However, in 2020 offsetting factors resulting from the pandemic appear to
have reduced the overall financial impact to insurers such as reduced healthcare claims and decreased medical costs
related to cancelled or delayed utilization of healthcare benefits. These offsetting factors are also evident in the
decreases in the loss ratios for several lines of business in 2020 as included in Table 2 above.

This significant increase in hospital and medical benefits in 2021 through 2023 now places the Health insurance industry
underwriting results more in line with financial results as reported pre-COVID19 pandemic in prior-year period 2019 in
relation to underwriting gains, net income, loss and administrative expense ratios and profit margin.
IMPACT OF CHANGES IN THE HEALTH INSURANCE MARKET
Health insurers are facing several changing market conditions that have the potential to significantly impact their
solvency position, including the unwinding of the public health emergency, as well as the potential for rising healthcare
costs due to inflation and provider consolidation.

The U.S. had been operating under a public health emergency declared by the federal government since the start of the
COVID-19 pandemic in 2020. This declaration has resulted in significantly expanded Medicaid or ACA coverage
enrollment, as well as special coverage rules for COVID-19 vaccines, tests, and treatments. However, due to the 2023
Consolidated Appropriations Act and the expiration of the public health emergency which occurred on May 11, 2023,
the Medicaid/ACA expansion and special coverage rules will now be phased out, which has the potential for significant
disruption in the health insurance market.

In what is being described as “The Great Unwinding”, it is estimated that 15-18 million enrollees could be at risk of losing
Medicaid or ACA coverage, which could create the biggest coverage event since the Affordable Care Act was
implemented. Further complicating the Medicaid unwinding is each individual state will develop its own timelines and
approach for “unwinding” the coverage requirements and will be required to re-enroll the impacted Medicaid
recipients. This unwinding has the potential to result in millions of consumers moving their coverage (or going without
coverage), which could result in significant growth or loss of members across various health insurers.

Insurers are also facing rising costs as they deal with elevated levels of inflation, and the continued trend of provider
consolidation, which have the potential to increase the cost of healthcare services and impact the underwriting
performance of health insurers.
ENROLLMENT
As shown in Figure 4, the industry has experienced an
incremental increase in total enrollment of 18% (41 million) to
274 million from 233 million through the second quarter of
2019.
The increase from 2019 is due primarily to:
• 36% (16 million) increase in Medicaid;
• 47% (8 million) increase in Medicare;
• 18% (6 million) increase in vision coverage;
• 14% (5 million) increase in policies that provide
Medicare Part D drug coverage;
• 11% (5 million) increase in dental coverage; and,
• 35% (4 million) increase in individual comprehensive
medical coverage.
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 U.S. Health Insurance Industry | 2023 Mid-Year Results

However, these lines were partially offset by:

• 15% (4 million) decrease in the group comprehensive line of business from the first six months of 2019.
As indicated above, the industry still experienced considerable growth in both Medicaid and Medicare. As a result of
increased unemployment rates caused by the pandemic, health care coverage has also been disrupted for millions of
people as most working-age adults receive health insurance coverage for themselves and their families through their
employer beginning in 2020. Many of those who lost health insurance coverage through their employer qualified for
Medicaid or had the opportunity to purchase individual health coverage through the exchange or other managed care
health providers. The shift in business concentration can also be attributed to an increase in the number of insureds
becoming eligible for either Medicare or Medicaid as evidenced by increases in enrollment in these lines. A certain
amount of the Medicaid enrollment increase is due to the continued expansion of Medicaid programs in certain states.

The industry recorded over 274 million members

enrolled in various types of health insurance
products. As shown on Figure 5, Medicaid
represents 22% of total enrollment; Dental 17%;
Vision 16%; Other Health comprised mostly by
Medicare Pt D 16%; Medicare at 10%; Group
Comprehensive 9%; and Individual Comprehensive
at 6%. A shift in business concentration can be
attributed to an increase in the number of insureds
becoming eligible for either Medicare or Medicaid as
evidenced by increases in enrollment in these lines.
A certain amount of Medicaid enrollment increases
is likely due to the continued expansion of Medicaid
programs in certain states.

As depicted in Figure 6 below, health entities’

earned premium per member per month (PMPM)
increased 22% over a five-year period to $332 from
$272 for the first six months of 2019, while claims
PMPM increased 23% to $286 from $233. It is
evident premium PMPM increased incrementally
through the five years illustrated in the graph below
while claims PMPM decreased in 2020 due to
decreased medical costs related to cancelled or
delayed medical utilization of healthcare benefits in
2020. As shown in the graph, the margin in 2021
returned to a margin more comparable to the pre-
pandemic periods due to folks returning to the
doctor’s office, seeking medical treatment,
procedures, and utilizing other medical benefits.
The increase in margin in the first six months of
both 2022 and 2021 can be attributed to the
increases in direct premium written in Medicare,
Medicaid, and individual comprehensive medical.

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 U.S. Health Insurance Industry | 2023 Mid-Year Results

PREMIUM REVENUES
Figure 4 above illustrates the growth in direct written premium. In comparison to the first six months of 2021, the
industry reported an 7% ($34 billion) increase in direct written premium to $544 billion from $510 billion. The increase is
primarily on the Medicare, and Medicaid lines of business.

Figure 7 illustrates the mix of direct written premium for the first six months of 2023. As insureds have become eligible
for either Medicare and/or Medicaid as evidenced by increases in enrollment in these lines, there has been a gradual
shift in the allocation of premium between the lines of business over the last five years. In comparison to the first half of
2022, direct comprehensive medical decreased to 30% from just under 31% of total written premium, while Medicare
increased to 36% from approximately 34%, Medicaid decreased to under 29% from just under 31%, and FEHBP remained
mostly unchanged at 4%.

Table 3 below provides a breakout of direct written

premium by line of business. The largest dollar
increases in written premium for the first six months of
2023 over the same period in the prior year was a 14%
($25 billion) increase in Medicare, a 12% ($6 billion)
increase in individual comprehensive, and a 3% ($4
billion) increase in Medicaid. It should be noted that
the increase in Medicaid direct written premium for
the six-month period of 2023 is the smallest increase
reported for the Medicaid line of business of the five
mid-year reporting periods included in the table
below.

Table 3
Direct Written Premium by Lines of Business
(In Millions) Chg. $ Chg. 2Q 2023 2Q 2022 2Q 2021 2Q 2020 2Q 2019
Indi vi dua l Comprehens i 12.1% $5,829 $53,807 $47,979 $41,421 $38,978 $39,535
Group Comprehens i ve 0.6% $492 $85,077 $84,585 $83,042 $83,226 $83,686
Medi ca re Suppl ement 5.1% $337 $6,908 $6,571 $6,318 $6,122 $5,782
Vi s i on 4.3% $63 $1,536 $1,473 $1,408 $1,365 $1,279
Denta l 5.3% $409 $8,130 $7,721 $7,392 $6,719 $7,008
FEHBP 4.0% $899 $23,318 $22,419 $21,491 $20,059 $19,872
Medi ca re 14.2% $24,491 $196,990 $172,500 $141,713 $126,752 $110,031
Medi ca i d 2.9% $4,477 $160,734 $156,257 $134,720 $118,435 $102,326
Other Hea l th 5.5% $615 $11,828 $11,212 $10,549 $10,861 $10,283

Table 4 on the next page includes direct written premium for the four largest revenue-generating lines of business as
reported by each state on Schedule T of the quarterly financial statement. The state of Florida reports the greatest dollar
amount of direct written premium on both the comprehensive medical and Medicare lines of business through the
second quarter of 2023. Florida recorded just under $17 billion in comprehensive medical premium after recording a
15% increase from the prior-year quarter while recording over $22 billion in Medicare premium, which is a 14% increase
from the prior-year quarter. The state of Texas reported just under $18 billion in Medicaid premium which is a 5%
decrease from the prior-year quarter. The state of Maryland reported just over $2 billion in premium revenue for the
federal employee health benefit plan line of business including a 5% increase over the prior-year quarter.
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 U.S. Health Insurance Industry | 2023 Mid-Year Results

Table 4 - Direct Written Premium by Line of Business by State

As reported on Schedule T
($ in Millions) Comprehensive Medical Medicare Medicaid FEHBP

State 2Q 2023 2Q 2022 % Chg. 2Q 2023 2Q 2022 % Chg. 2Q 2023 2Q 2022 % Chg. 2Q 2023 2Q 2022 % Chg.

Alabama $3,217 $3,004 7.1% $4,335 $3,916 10.7% $29 $19 53.5% $482 $402 19.8%
Alaska $338 $319 5.9% $3 $3 19.0% $0 $0 0.0% $304 $264 15.4%
Arizona $2,076 $1,824 13.9% $4,023 $3,592 12.0% $138 $138 0.2% $391 $373 4.7%
Arkansas $2,177 $2,039 6.8% $2,129 $1,702 25.1% $793 $805 (1.5)% $167 $160 4.7%
California $1,377 $1,428 (3.6)% $2,684 $2,389 12.3% $0 $0 0.0% $3 $3 (1.8)%
Colorado $2,711 $2,794 (3.0)% $3,321 $2,952 12.5% $757 $657 15.2% $504 $437 15.4%
Connecticut $1,550 $1,582 (2.0)% $2,282 $2,217 2.9% $0 $0 0.0% $185 $180 2.7%
Delaware $409 $387 5.7% $416 $323 28.9% $0 $0 0.0% $108 $95 13.4%
District of Columbia $1,167 $1,126 3.7% $283 $232 22.0% $1,029 $912 12.7% $899 $905 (0.7)%
Florida $16,694 $14,498 15.1% $22,402 $19,721 13.6% $11,226 $11,517 (2.5)% $1,513 $1,443 4.8%
Georgia $5,069 $4,701 7.8% $7,255 $6,024 20.4% $3,806 $2,852 33.4% $975 $850 14.7%
Hawaii $1,839 $1,768 4.0% $1,122 $1,005 11.6% $1,082 $1,127 (4.0)% $280 $240 16.6%
Idaho $1,238 $1,090 13.6% $1,037 $906 14.4% $276 $317 (13.1)% $146 $113 29.9%
Illinois $9,361 $8,859 5.7% $6,001 $5,840 0.0% $9,329 $8,159 14.3% $621 $706 (12.1)%
Indiana $1,999 $1,964 1.8% $4,283 $3,659 17.0% $5,055 $4,188 20.7% $386 $381 1.3%
Iowa $2,088 $1,917 8.9% $1,512 $1,277 18.4% $3,246 $2,983 8.8% $151 $151 0.1%
Kansas $756 $700 8.1% $1,325 $1,029 28.7% $2,326 $2,047 13.6% $73 $69 6.0%
Kentucky $1,808 $1,832 (1.3)% $3,536 $3,091 14.4% $5,553 $4,934 12.5% $294 $267 10.2%
Louisiana $2,195 $2,106 4.2% $3,637 $3,154 15.3% $5,943 $5,568 6.7% $261 $255 2.3%
Maine $920 $919 0.0% $1,057 $942 12.3% $0 $0 0.0% $129 $124 3.6%
Maryland $2,590 $2,525 2.6% $1,791 $1,344 33.2% $1,877 $1,784 5.2% $2,149 $2,041 5.2%
Massachusetts $7,084 $6,845 3.5% $2,229 $1,983 12.4% $3,749 $2,981 25.7% $456 $485 (6.0)%
Michigan $7,437 $7,009 6.1% $8,119 $6,690 21.4% $4,673 $4,193 11.4% $465 $399 16.8%
Minnesota $3,364 $3,376 (0.3)% $3,598 $3,247 10.8% $5,222 $4,841 7.9% $388 $364 6.4%
Mississippi $1,192 $1,105 7.9% $1,730 $1,407 22.9% $1,058 $976 8.4% $221 $183 20.6%
Missouri $2,339 $2,296 1.9% $4,874 $4,203 16.0% $2,881 $1,665 73.0% $405 $409 (0.8)%
Montana $598 $559 6.9% $416 $348 19.4% $0 $0 0.0% $113 $118 (4.3)%
Nebraska $1,175 $1,166 0.7% $814 $685 18.8% $1,203 $1,146 5.0% $169 $137 23.3%
Nevada $1,375 $1,460 (5.8)% $2,264 $1,956 15.8% $1,200 $1,212 (1.0)% $142 $124 14.6%
New Hampshire $893 $858 4.1% $554 $448 23.6% $620 $629 (1.4)% $172 $170 1.0%
New Jersey $4,684 $4,758 (1.6)% $3,879 $3,326 16.6% $7,958 $6,881 15.6% $563 $522 7.9%
New Mexico $557 $539 3.3% $1,336 $1,139 17.4% $3,109 $3,266 (4.8)% $210 $150 40.0%
New York $11,986 $11,903 0.7% $11,750 $10,389 13.1% $5,851 $5,191 12.7% $907 $940 (3.5)%
North Carolina $5,233 $4,642 12.7% $7,585 $6,375 19.0% $4,179 $3,741 0.0% $689 $622 10.7%
North Dakota $888 $848 4.7% $183 $133 36.8% $207 $199 3.6% $75 $66 13.9%
Ohio $4,769 $4,636 2.9% $9,227 $7,733 19.3% $9,517 $11,194 (15.0)% $785 $709 10.7%
Oklahoma $2,132 $1,988 7.2% $2,199 $1,753 25.4% $0 $0 0.0% $366 $388 (5.7)%
Oregon $3,217 $3,080 4.4% $3,068 $3,049 0.6% $4,136 $3,625 14.1% $282 $279 1.0%
Pennsylvania $6,934 $5,933 16.9% $9,734 $9,164 0.0% $16,359 $15,304 6.9% $897 $743 20.8%
Rhode Island $637 $625 2.1% $1,680 $725 131.8% $367 $1,134 (67.6)% $76 $62 22.4%
South Carolina $2,654 $2,242 18.4% $3,440 $2,967 16.0% $1,971 $1,893 4.1% $338 $344 (1.7)%
South Dakota $786 $730 7.7% $263 $211 24.7% $0 $0 0.0% $102 $112 (8.6)%
Tennessee $2,721 $2,351 15.7% $5,406 $4,734 14.2% $3,438 $3,423 0.4% $458 $428 7.1%
Texas $16,013 $13,274 20.6% $19,762 $16,615 18.9% $17,941 $18,813 (4.6)% $1,469 $1,805 (18.6)%
Utah $1,976 $1,800 9.8% $1,395 $1,213 15.0% $647 $640 1.1% $343 $342 0.4%
Vermont $399 $379 5.4% $272 $211 28.9% $0 $0 0.0% $59 $49 19.8%
Virginia $3,772 $3,799 (0.7)% $3,982 $3,378 17.9% $7,646 $6,797 12.5% $1,691 $1,434 17.9%
Washington $4,895 $4,628 5.8% $4,376 $3,840 13.9% $4,457 $4,375 1.9% $623 $564 10.5%
West Virginia $780 $566 38.0% $1,539 $1,321 16.5% $1,250 $1,209 3.4% $259 $223 16.1%
Wisconsin $4,175 $4,005 4.3% $4,036 $3,543 13.9% $1,540 $1,450 6.2% $364 $367 (0.7)%
Wyoming $358 $323 10.6% $83 $39 113.8% $0 $0 0.0% $63 $60 4.2%
American Samoa $0 $0 0.0% $0 $0 0.0% $0 $0 0.0% $0 $0 0.0%
Guam $57 $44 31.7% $0 $0 0.0% $0 $0 0.0% $13 $12 1.3%
Puerto Rico $663 $642 3.3% $4,147 $4,015 0.0% $1,973 $1,642 20.1% $119 $110 0.0%
U.S. Virgin Islands $4 $3 3.9% $23 $21 0.0% $0 $0 0.0% $1 $1 14.2%
Northern Mariana Islands $1 $1 3.9% $0 $0 0.0% $0 $0 0.0% $0 $0 0.0%
Aggregate Other Alien $0 $643 (100.0)% $0 $0 0.0% $0 $0 0.0% $0 $0 0.0%
Grand Totals $167,379 $156,436 7.0% $198,397 $172,178 15.2% $165,616 $156,434 5.9% $23,301 $22,180 5.1%

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© 2023 National Association of Insurance Commissioners
 U.S. Health Insurance Industry | 2023 Mid-Year Results

CASH FLOW AND LIQUIDITY

The health insurance industry reported a
significant increase in operating cash flow to
$66 billion in the first half of 2023 as compared
to operating cash flow of $26 billion in the first
half of 2022. The considerable increase in
positive cash flow is due primarily to a 17% ($84
billion) increase in premiums collected partially
offset by 10% ($42 billion) increase in benefits
and loss-related payments.

As illustrated in Figure 8, liquid assets and

receivables increased 14% ($55 billion) to $447
billion in the first six months of 2023 as
compared to the prior year period while current
liabilities increased 21% ($49 billion) to $278
billion. This resulted in a decrease in the ratio of
liquid assets and receivables to current
liabilities to 161% from 171% for the period ended June 30, 2022.

CAPITAL AND SURPLUS

Health entities reported a 6% ($12 billion) increase in Figure 9
capital and surplus to over $213 billion from over $201 Capital & Surplus Account
billion at Dec. 31, 2022, as illustrated in Figure 9. The
increase is due primarily to net income of $18 billion, a
$3 billion increase in unrealized capital gains and
additional paid-in surplus of $1 billion. However, these
items were partially offset by, dividends of $5 billion
paid to stockholders, and a $2 billion increase in non-
admitted assets.

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© 2023 National Association of Insurance Commissioners
 U.S. Health Insurance Industry | 2023 Mid-Year Results

Financial Regulatory Services Division

Financial Analysis and Examinations Department
Contacts:
Bill Rivers, Health Financial Analysis Program Manager
[email protected]
816.783-8142
Bruce Jenson, Assistant Director Solvency Monitoring
[email protected]
816.783.8348
Jane Koenigsman, Sr. Financial Analysis Manager II
[email protected]
816.783.8145

Disclaimer: The NAIC 2023 Mid-Year Health Insurance Industry Analysis Report is a limited scope analysis based on the
aggregated information filed to the NAIC’s Financial Data Repository as of June 30, 2023, and written by the Financial
Regulatory Services Department staff. This report does not constitute the official opinion or views of the NAIC
membership or any particular state insurance department.
Health Industry Disclosure: In some states the health industry is regulated by a Department/Office of Insurance other
than the Department of Insurance. Therefore, not all health insurers may be required to file financial statements with
the NAIC.

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© 2023 National Association of Insurance Commissioners