Ongoing headwinds caused by elevated utilization and medical costs continued to drag major health plans in the fourth quarter, completing the story of a complex 2025 for the industry.
The most profitable company for the full-year was UnitedHealth Group, with $12.05 billion in earnings for 2025. The healthcare giant had a sizable lead on the next-highest payer in terms of profitability, which was Cigna at just below $6 billion.
However, the company posted just $10 million in profit for Q4, the lowest tally among payers that turned a profit in the quarter. In Q4, the company saw a medical loss ratio of 92.4%, which settled to 89.1% for the full year.
UnitedHealth also had the highest revenue for 2025, bringing in $447.6 billion. The company also topped the list for fourth quarter revenue, with $113.2 billion.
Across the six major payers, all were profitable for the year—even if by a slim margin—except Centene, which posted a loss in both Q4 and across 2025 amid turmoil in Medicaid and the individual market.
Centene lost nearly $6.7 billion across the entire year and $1.1 billion in the fourth quarter alone. The company faced rising acuity and cost in Medicaid and marketplace plans, even as both segments were roiled by significant policy uncertainty and change.
Centene CEO Sarah London said that behavioral health was one of the biggest challenges in Medicaid, and that the company has honed in on improvements there as it looks to bolster overall performance in this space.
For revenue, Centene reported $194.8 billion for the full year and $49.7 billion in Q4.
In addition to the struggles that Centene and others faced in Medicaid and the Affordable Care Act segments, the Centers for Medicare & Medicaid Services released its proposed 2027 rate notice for Medicare Advantage in the midst of payer earnings.
All three of the leading insurers in MA —UnitedHealthcare, Humana and CVS—said that the agency's plan for flat rates in 2027 fails to meet the needs of the current moment. CVS CEO David Joyner said the "'disappointing" notice does not fully account for rising medical costs in Medicare Advantage, a trend that has been ongoing for at least two years.
CVS reported 2025's second-highest revenue number at $402.1 billion, with fourth-quarter revenues similarly second place to UHG at $105.7 billion. CVS posted $2.9 billion in profit in Q4, with its full-year tally at $1.8 billion.
Beyond the pressures in its insurance business, CVS has been making strategic changes to boost the performance of its Oak Street Health unit, and expects financial waters to be less choppy in 2026.
Humana executives said the company is poised to adapt to the market should CMS finalize the rates as proposed. As its insurance business is concentrated in Medicare Advantage, it felt the pressures in this market first and began addressing those challenges sooner.
However, the insurer did see an unexpected enrollment bump during the annual enrollment period that could throw a wrench into its plans for performance improvement.
Humana posted $1.2 billion in profit for 2025 and $796 million for the fourth quarter. Its full-year revenues were $129.7 billion, and its Q4 haul was $32.5 billion.
Cigna's nearly $6 billion profit in 2025 just edged out Elevance Health, which posted $5.7 billion for the year. The company's $1.2 billion in profit sat squarely in the middle of this list.
Cigna also reported $274.9 billion in revenue for the full year and $72.5 billion in the fourth quarter.
While Cigna experienced similar cost pressures on its insurance business, the company's membership is concentrated in the employer-sponsored market, which has been less volatile in the policy space even as expenses rise. It's also focusing on major shifts for its pharmacy benefit management business that move on from rebates and align with reform efforts on the Hill.
Elevance Health's Q4 profit was $547 million, and the company set a "prudent" outlook for the year amid the myriad pressures facing health insurers. It posted $199.1 billion in revenue for the full year 2025, as well as $49.7 billion in the fourth quarter.
CEO Gail Boudreaux told investors that the company's focus for 2026 is on margin improvement as it navigates the ongoing headwinds, calling it a "year of execution and repositioning."