In recent weeks politicians and the media have been preoccupied with ISIS, Donald Trump and “Star Wars: The Force Awakens,” marking a major shift in attention away from Obamacare. After dominating the media cycle with its rocky start, including crashing enrollment websites, Republican votes to repeal the legislation (61 votes so far), and damning forecasts of spiraling costs, millions of previously chronically uninsured people now have access to medical care. It is not an understatement to make the claim that lives were likely saved as a result of Obamacare, but alas our collective attention is on to different things these days. (For related reading, see: How Obamacare Affected the Insurance Industry.)

Financial Benefits of the Affordable Care Act

The benefits to these newly insured are clearly significant. Studies have shown 30 – 50% reductions in mortality from having health insurance, not to mention reduced fear and anxiety, and the potentially ruinous financial burden that comes from going without insurance. But the benefits don’t just stop with the individuals the legislation helped. The Affordable Care Act created legions of newly minted medical consumers which benefited the bottom line of the companies that cared for them, their executives, and investors who enjoyed incredible stock returns.

For investors who bet on healthcare stocks during the roll out of the ACA, the portfolio returns have been stellar. While the S&P 500 returns were great over the same time frame, the Health Care Select Sector SPDR Fund (XLV) was better by a substantial margin. From the beginning of 2013, the year before the roll out, to the peaks of 2015, the S&P 500 was up +47.8% while the XLV nearly doubled that effort by rising +91.1%.

For the hospitals, who likely saw the most incremental benefit, increased patient volume and less unpaid charity care led to stock returns of +141.6%. In small terms, a $10,000 investment in a basket of hospital stocks would have peaked a few months ago at over $24,000. In big terms, the XLV added an additional $5.0 billion in market capitalization over the same period going from $12.7 billion to $18.7 billion. Helping people get insured has its benefits.

The reason the portfolio returns were so big is because the tide of newly insured medical consumers was so large; the largest in over 30 years by our estimate. Since its passage, the U.S. Medical Economy has witnessed the largest inflow of approximately 25 million new medical consumers between the approximately 10M Public Exchange enrollees and approximately 15M new Medicaid beneficiaries. First, insured people spend two to three times the amount that their uninsured counterparts do. Second, these new consumers carried with them above normal per capita spending due to years of pent-up demand associated with being chronically uninsured. (For more, see: Essential Health Benefits Under the Affordable Care Act.)

If we sum the total spending capacity of the Public Exchange enrollees and their Medicaid Expansion counterparts we can estimate there was as much as $120 billion in new money available to spend on physician visits, lab work, prescriptions and hospital care.  

Historical Context

Let’s put those enrollment figures into historical context. In 1996, the next best year for increases in the number of insured medical consumers, the U.S. Medical Economy added +3.2 million people to the insured population. In other words, we just added eight times that number in just over one year. It seems likely that such a boom in new consumers with high need could lead to 100% plus stock returns.

All good stories come to an end eventually and the ACA is no exception. The whirlwind of interest around Trump and ISIS and “Star Wars” will taper off just as the Obamacare story faded. But just because the ACA is not making the news, it does not mean the stocks will hold onto their gains.

Future Healthcare Stock Trends

Heading into 2016 we will enter a period we are calling the #ACATaper, when the benefits of millions of new medical consumers and the money to pay for their care tapers off back to slow to negative growth and the industry resumes grappling with the litany of cost pressures that existed before Obamacare, and will certainly exist after it. The double digit growth in medical consumers in 2014 and 2015 will head to 0% and lower in 2016. In 2016, patients will have already attended to their most pressing medical needs that they had put off dealing with. The revenue and profit growth that was so great in 2014 and 2015, and pushed stocks far higher than the market, will likely turn negative in 2016. 

The ACA has created a year-over-year comparison so enormous that healthcare stocks will probably unwind rather violently. In fact, there is already evidence that the taper is underway as we have already seen an abrupt about-face for the industry. The XLV has declined -4.8% while the S&P 500 is essentially flat, down only -0.3% from the 2015 peak. Hospital stocks are down a whopping -16.8% from the peak. The unwinding might even make our “taper” phrase too gentle. (For more, see: Top Healthcare Stocks Fueled by Obamacare.)

Consider David Scott Wichmann. He’s the President and CFO of the colossal $107 billion insurance company UnitedHealth (UNH). During the company’s third quarter earnings call just a few months ago, he called the ACA’s Public Exchanges “a strong, viable market for us.” Compare that rosy picture UNH painted with a statement in a press release just one month later:

“UnitedHealth has pulled back on its marketing efforts for individual exchange products in 2016. The Company is evaluating the viability of the insurance exchange product segment and will determine during the first half of 2016 to what extent it can continue to serve the public exchange markets in 2017” (UNH 2015 earnings update, Nov. 19, 2015).

Shares fell almost -4% following the news and after UNH revised its guidance down -12%.

This wasn’t an isolated incident. Hospital operator HCA Holdings (HCA) earnings plunged 31% after overstaffing their hospitals for patients that didn’t show up. Companies who benefited from the ACA were not alone in missing expectations this past earnings season. These recent developments dovetail with our overall #ACATaper theme. We continue to anticipate that pent up demand will decline in the coming quarters and the ACA consumption contribution will turn negative. 2016 is setting up to offer up some nasty stock surprises.

The ACATaper is just one small part of the Obamacare story, and the story of the U.S. Medical Economy. Beyond 2016, there are additional industry headwinds to consider which the ACA either masked or exacerbated.  

Demographics are putting downward pressure on pricing as Baby Boomers are graduating into Medicare leaving their employer-based commercial insurance behind. Since Medicare already pays providers poorly, and will continue to have to pay for the care of a population which grows faster than their budget, the negative impact is going to get worse from here. Meanwhile, the number of working age people, insured by their employer, Medicaid, or a Public Exchange product will likely remain flat as the total population remains flat at 190 million people for years to come.

These demographic trends will occur as healthcare affordability nears its natural limits. The data suggests there simply isn’t any remaining room to sustain rising premiums peak out of pocket expense, employer premium contribution, and state and federal budgets for Medicaid and Medicare.

Long-Term Benefits of Obamacare

One of the great alterations that Obamacare made to the U.S. Medical Economy, among the many others, is the rise of information technology in the delivery of healthcare. The highly likely outcome over the years to come is that Americans receive better care at a cheaper price; a crazy idea after 50 years of excess healthcare inflation. Breaking the inflation cycle will be one of the great benefits of Obamacare.

Anecdotally, I am already hearing about this in conversations with surgeons and providers across the country. At the surgeon level, they are receiving monthly reports about their patient volume, the itemized cost of the procedure, what insurance paid, as well as the downstream costs. Peer pressure is having an impact on the outliers and helping some surgeon groups make substantial and positive changes. In one instance, technology systems helped an orthopedic surgery group reduce expensive post-acute care by 30%. At the provider level, hospital systems are preparing for caring for huge populations of people, paid for in lump sum capitated payments and measured by care quality scores.

The Bottom Line

The great hope I have for the U.S. Medical Economy is that with millions of more insured people, deflationary pressures, and the advent of real technology, we will see a massive turnover in the healthcare market capitalization now included in the S&P 500 Index. We’ll certainly witness the emergence of new delivery models, new products, and new technology that makes prices more transparent and the system more efficient. For this longtime observer, it couldn’t come soon enough.

While I’m ever hopeful, we all might have to wait a bit longer than we’d like. Much of this exciting innovation is sequestered out of sight in the world of private investment and venture capital, or yet to be developed at all. For now, given what we think unfolds in 2016, we would encourage investors to approach healthcare stocks with extreme caution in the short term. That’s why our list of shorts is far longer than our longs these days, and it’s going to be a while before that changes.   

Hedgeye is an independent, conflict-free investment research and online financial media company. Our all-star research team of over 30 analysts across myriad sectors—from Macro, Energy and Industrials, to Retail, Financials and Healthcare—is committed to delivering actionable investment ideas of the highest caliber through rigorous quantitative, bottom-up and macro analysis with an emphasis on timing. Click here to learn more.

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